LIBRARY OF CONGRESS, 



"WB 2.7 

Sipp + ©0ptp*jg^i Ifta 

Shelf.^CLk-fc 

UNITED STATES OF AMERICA. 







Spirilla cholerse Asiaticae, showing flagella. X 1000. (Photo-micrograph by Professor John 

GUITf-RAS, M.D.) 




Encysted trichina spiralis, in the injected tongue ol a cat. X about 150. (Photo-micrograph 
by Dr. J. P. TUNIS, from a specimen prepared by the author. Trans. Path. Soc. of Phila., vol. 
xv., page 282.) 



NOTES 



ON THE 



DEMONSTRATIONS IN MORBID ANATOMY 

(INCLUDING AUTOPSIES), 



DELIVERED IN THE MEDICAL DEPARTMENT OF THE 

UNIVERSITY OF PENNSYLVANIA BEFORE 

THE THIRD- YEAR CLASS. 



BY 



HENEY W. CATTELL, A.M. M.D., 

DEMONSTRATOR OF MORBID ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA ; FELLOW OF THE 

COLLEGE OF PHYSICIANS ; PROSECTOR TO THE AMERICAN ANTHROPOMETRIC SOCIETY ; 

PATHOLOGIST TO PRESBYTERIAN HOSPITAL, THE INSTITUTION FOR 

FEEBLE-MINDED CHILDREN AT EL'WYN, ETC. 



LLUSTRATED. 



MAY 5 1894 r °) 

Of WASH** " 



PHILADELPHIA: 

INTERNATIONAL MEDICAL MAGAZINE CO. 

716 Filbert Street. 
18 94. 



Entered according to the Act of Congress, in the year 1894, 
HEXET W. CAT TELL. 
In the Office of the Librarian of Congress, at "Washington. All rights reserved. 



rOBSAX. PRINTER 



PREFACE. 



The following pages are printed in order that the work of the 
Third- Year Class may be rendered slightly easier. They are far 
from forming a complete course in Morbid Anatomy. Much 
material contained in the able didactic lectures of the Professor 
of Pathology, Dr. John Guiteras, is necessarily gone over in 
the demonstrations, but is either omitted in the notes or else stated 
in the briefest possible manner. 

My thanks are due to many of my former students for the valu- 
able aid which they have given me in the preparation of the notes. 
I am especially indebted to Dr. G. K. Edwards, Dr. J. P. Tunis, 
Mr. Frank Sckeaffer, Miss McCaffery and Miss Sinclair for most 
of the illustrations (which were made under the supervision of the 
author) ; to Mr. J. W. Brandon for his notes on the demonstra- 
tions taken during the session of 1892-'93 ; and to Drs. J. A. 
Scott, F. E. Murphy, and A. W. Peckham, and Messrs. A. A. 
Poehner and X. V. Shannon for their practical suggestions. 

" Practical Pathology," by Woodhead, third edition ; Osier's 
" Practice of Medicine," or Pepper's "American Text-Book of the 
Theory and Practice of Medicine;" " Principles and Practice of 
Surgery," by Ashhurst ; " or "American Text-Book of Surgery," 
by Keen and White, contain, practically, all the pathological 
information necessary. The seventh German edition of Ziegler's 
" Pathology," the new English translation of which is not com- 
pleted, is by far the best single work on the subject. 

Frequent references are made to Gowers' " Diseases of the 
Nervous System ; " Keating's " Cyclopaedia of the Diseases of 
Children ; " Orth's " Pathologisch-anatomische Diagnostik ; " 



iv PREFACE. 

A] - mT;" Piersol's " Text-Book of Histology;'* 
- - - Innocent and Malignant;" Peyer's "Atlas 

Mikr^-kopie am Krankenbette ; " v. Jaksoh's ,w Klinisehe 
Diagnostic f Klein's u Histology ; " •• Clinical Manual." by Fin- 
lavson : Pepp- - 3 "stem of Medicine:*" Foster's "Encyclopaedic 
■ lieal Dictionary: " Sajouss " Annual of the Universal Medical 
Ball's Essentials of Bacteriology : Virehow's 
"Archives:" Eisenberg's *■ Bakteriologische Diagnostik ;*' Quain's 
•• Dictionary of Medicine : '* Reese- ■■Medical Jurisprudence 
Hamil: - Text-Book of Pathology:" "Transactions of the 
Philadelphia Pathological Society:" Ewald's "Diseases of the 
?t maeh.*' and many magazine articles in current medical litera- 
ture. 

Classifications and definitions used by Professor Guiteras in his 
lectures are marked with a *. 

_**55 WO0BEA3TD AVE2TCE. April, 1 • -. 



CONTENTS. 



PART I. 

PAGES 

General Pathology 9-88 



PART II. 

Post-mortems ■ . 89-136 



PART III. 

Special Pathology . . 137-172 



PART I. 

GENERAL PATHOLOGY. 



Pathology has been defined as having everything to do with 
disease except its treatment. It represents the scientific side of 
medicine, and should, therefore, be studied in connection with all 
the various branches of medicine. In France they call medicine 
internal pathology, and surgery external pathology. 

For convenience of study, pathology is divided into : 

1. Etiology : the study of the causation of disease. The greatest 
advancement in medicine of late years has been due to the discov- 
eries made in bacteriology. Lister put into practical use these 
discoveries when he placed antiseptic surgery on a firm basis. 

2. Morbid Anatomy : the study of the changes of structure in 
disease ; whether these changes be macroscopic or microscopic. By 
macroscopic is understood that the morbid changes in the tissue or 
organ are readily seen with the naked eye — often used synonym- 
ously with gross, as in gross morbid anatomy. By microscopic 
is understood that the morbid changes are made visible by means 
of amplification of the object by the use of a magnifying glass or 
lens. 

3. Morbid Physiology : the study of the changes of function in 
disease. These changes involve such complex chemical reactions 
that they are but little understood. 

For convenience of study, pathology is divided into General and 
Special Pathology. Morbid processes, whether elementary or 
compound, occurring in different organs or tissues, are treated 
under General Pathology ; while those processes occurring in par- 
ticular organs or tissues are spoken of as belonging to Special 
Pathology. 

At the beginning of your pathological studies learn to imagine 
that each specimen seen has formed an integral portion of a living 
human being. When you see an aneurism of the arch of the aorta, 
think of the person in whom it was found and the changed anatom- 

2 



10 GENERAL PATHOLOGY. 

ieal relations and the altered functions which produced it, and were 
produced by it : and, conversely, when you are examining a person 
afflicted with disease, try to imagine to yourself the pathological 
changes which are going on in the living body. In this manner 
vou will best be able to fit yourselves to perform your duties as 
future members of the medical profession. 

In General Pathology it is useful to study first the elementary 
pathological processes, which may be either progressive (inte- 
grating), or retrograde (disintegrating); then the composite 
pathological processes ; and, lastly, the specific diseases. 

Hypertrophy. 
Physiological example : Growth of a child. 

A. 

1. Simple. Ex., uterus ; heart. 

2. Xumerical. Ex., supernumerary organs, as of the spleen. 

B. 

1. True. a. Compensative. Ex., left ventricular hypertrophy, 
in general arterio-capillary fibrosis, b. Congenital. Ex., acro- 
megaly, polydactylism. 

2. False or pseudo. Ex., hypertrophic cirrhosis of the liver ; 
pseudo-hypertrophic muscular paralysis. 

Fresh specimens (not necessarily pertaining to the above subject). 



Exhibits. 

1. Foetus in utero. 

2. Slides showing normal and hypertrophied muscle fibres from 
the uterus. 

3. Supernumerary spleen-. 

4. Arteries from a case of collateral circulation. 
•";. Heart showing left-sided hypertrophy. 

Pictures from a case uf acromegaly. 
7. Specimens of polydactylism. 



HYPERTROPHY. 



11 



8. Slide showing hypertrophic cirrhosis of the liver. 

9. Picture of a child raising itself from the ground in pseudo- 
hypertrophic muscular paralysis. 

10. Slide of muscle from a case of pseudo-hypertrophic mus- 
cular paralysis. 

Like a great many other words in medicine, hypertrophy is 
used in both a general and in a special way. In a general way it 
refers to the enlargement of an organ, no matter to what cause it 
may be due ; while true hypertrophy consists in an enlargement of 
an organ due to the fact that the relation of the pre-existing cells 
is not materially changed, and that the increase is due either to an 
increase in size (simple hypertrophy) or number (numerical 
hypertrophy) of the cells. 

In this enlargement of an organ there is nothing new added 
from without, and the constituent parts of an organ are better 
nourished and more work is demanded of and accomplished by 
such an organ. 

Fig. 1. 



f. c. 




e. c. 



I. c. 






\ 












a. c. t. 

Hypertrophic cirrhosis of the liver. Notice that the connective tissue, which is the unim- 
portant portion of the liver, is largely increased above the normal, x 300. (Woodhead.) 

e. c. Columns of liver cells at the margin of a group of lobules. Between these columns 
young connective tissue is seen. /. c. Liver cell infiltrated with fat. I, c. Atrophied and 
flattened liver cells shaved off from the main body by the encroaching connective tissue, c. t. 
a. Small branch of the hepatic artery. 

In the use of pseudo-hypertrophy there is a contradiction of 
terms, for how can a thing be true and false at the same time ? 
The constituent of the tissue that is here increased in amount is 
usually the unimportant one, namely, the connective tissue, as in 
hypertrophic cirrhosis of the liver. (See Fig. 1.) 



12 



GENERAL PATHOLOGY 



Fig. 2. 



Iii simple hypertrophy there is an enlargement of the pre-exist- 
ing eells. In the uterus daring pregnancy the cells may be in- 
creased fifteen to twenty times above what they are when in a state 

of inactivity. (See Fig. 2.) In the 
heart and elsewhere this increase in 
size of the cells is more difficult to 
demonstrate. 

In numerical hypertrophy there is 
an increase in the number of cells ex- 
isting in the part. This is often called 
hyperplasia ; while others employ this 
word in a more general sense, using it 
as a synonym of a neoplasm or new 
growth. 

It is easily seen that both physio- 
logically and pathologically hypertro- 
phy will consist in both an increase in 
the number and the size of the cells of 
an organ, as is seen in the enlargement 
of the previously formed vessels in the 
establishment of a collateral circulation. 
In true hypertrophy, where more work 
is gotten out of an organ, we may have 
it due to the fact that it is compensative. 
This is illustrated by the overgrowth of a kidney which has had 
to do not only its own share of work, but also that of the opposite 

Fig. 3. 



Muscular fibre-cells from the 
uterus three weeks after delivery, 
treated with acetic acid. The en- 
larged fibres are now undergoing 
atrophy by means of fatty degen- 
eration. X 350. (Kolliker. From 
Quain's Anatomy.) 

a, nucleus ; b, fat-granules. 




Transverse section through the ventricles of the heart in a case of insufficiency and sten- 
osis of the aortic valves. The left ventricle (on the right of the illustration) is hypertrophied 
to at least twice its normal thickness. Half natural size. (After Ziegler.) 

kidney, which may have been excised or damaged bv disease. 
Another example is the hypertrophy of the left ventricle of the 



HYPERTROPHY. 



13 



heart, which occurs in those persons affected with arterio-capillary 
fibrosis or aortic stenosis. (See Fig. 3.) 

Hypertrophy may occur congenitally. This is well seen in 
acromegaly, a disease which has attracted considerable attention of 
late. This consists of an overgrowth of the extremities, often 
associated with an enlargement of the facial bones and deformity 
of the vertebrae. It occurs in young and middle-aged people, 
rarely in those who are advanced in years. The increase is in the 
breadth of the bone, and not in the length, and shows numerous 
exostoses on their ends. The cause is not known. 1 For a picture 
of this condition see Marie's picture in Osier's account of this dis- 
ease in Pepper's Text-booh of Medicine. 

In a case of polydactylism, also an illustration of congenital 
hypertrophy, which occurred in a female body in the dissecting- 
room of the University in 1886, there was an extra finger to each 
hand, and an extra toe to each foot. (See Fig. 4.) 

Fig. 4. 







Case of polydactylism. 

Pseudo-hypertrophic muscular paralysis 2 is due to a defective 
tendency of development of the germinal tissue which forms 
muscle. It is therefore congenital, while rarely hereditary ; and 
if so, is inherited through the mother, as in the case of hsemato- 
philia, Several members of the same family may be affected, as 
in the case of three brothers at Elwyn, studied by Drs. Kerlin, 
Mills, and Wilmarth. Males are four to seven times more fre- 
quently affected, and in females the disease is milder, of later 
manifestation, less likely to cause death, and no doubt more fre- 
quently overlooked. It is a disease of early life, though rarely 
it may not have been noticed until after puberty, though in all 
probability it has been progressing for several years and has been 



1 Ziegler : Seventh edition, p. 179. 

2 See Gowers ; second edition, p. 503, et seq. 



14 



GENERAL PATHOLOGY. 



overlooked. The muscles of the calf are most frequently affected, 
the infra-spinatus next. The intrinsic muscles of the hand usually 
escape, and thus aid us in diagnosing the disease from spinal mus- 
cular atrophy, where they are usually primarily affected. The 
latissimus dorsi may be congenitally absent. The calf of a boy aged 
eight mav measure in circumference as much as it should at four- 
teen. The mode of rising from the ground is quite characteristic, 
the child using the lower limbs as a ladder upon which he climbs, 
in order to gain the erect position. (See Figs. 5, 6, and 7.) Later 



Fig. 5. 




Method of getting up from the ground in a case of pseudo-hypertrophic muscular 



paralysis. First position. 



Fig. 6. 



Fig. 





Second position. 



Third position : The characteristic one where 
the child climbs up its own limbs, using them 
as a ladder. (After Gowers.) 



on the joints become distorted, and curvature of the spine often 
occurs. The reaction of degeneration is never present, though 
there may be a diminution both to the faradic and galvanic cur- 
rents. The knee-jerk may be normal, and finally become lost. 
The muscles are pale and yellowish in color, the resemblance to 
fat being often well marked. Under the microscope the degener- 
ated, narrowed, and irregular shapes of the voluntary muscles are 
found pressed together by connective tissue and a large amount of 
fat. (See Fig. 8.) There is no primary lesion of the brain, cord, 
or motor nerves, as was formerly believed, the degenerative changes 
in the anterior horns being no more than could be accounted for 
by the disuse of the muscles. During life the pathologist is some- 



ATROPHY. 



15 



times called upon to remove some of the muscles for examination. 
This is done by " harpooning " some of the muscles of the calf 



Fig. 8. 




Slide showing muscle from a case of pseudo-hypertrophic muscular paralysis. The 
atrophied muscle, the fat, and the connective tissue are well shown. (Gowers.) 

and examining by the microscope, care being taken that the sub- 
cutaneous fat be not mistaken for muscle that has undergone fatty 
degeneration. 

Atrophy. 

Phys. ex. : Thymus gland. 

A. 

1. Simple. 

2. Numerical. 

3. Combination of 1 and 2 most usual form. Ex., chronic 
spinal muscular atrophy. 



1. Active. 

2. Passive. 



B. 



a 



1. Senile. Ex., organs of generation at the menopause. 

2. Inactive. Ex., muscles of arm after a fracture. 



CtZXZ?. a: pathology. 

Trophoneurotic. Ex.. myelin-. 
4. Piormentarv. Ex.. brown atrophy of the heart. 

Pressor-. Ex.. aneurism of arch of the aorta, eroding bone. 
Starvation. 

sh specimens. 



Exhibits. 

1. Engraving showing normal position of the thymus gland. 
_ Atrophied spleen, showing marked pigmentation. Weight. 
] "3 _ rains. 

Picture of a case of chronic spinal muscular atrophy. 
4. Slide from a case : spinal muscular atrophy. 
1 train, she wing atrophy. 

rns and appendages of a senile woman. 

7. Slide, showing brown atrophy of heart. 

8. Aneurism, eroding bone. 

Atrophy is a diminution in the size of an organ or part, due to 
a primary decrease in the size ( simple atrophy) ; and a secondary 
decrease in the number (numerical atrophy) of the cells forming 
such an organ or part. Smallness of an organ does not therefore 
actually constitute atrophy, unless the cells which previously ex- 
been diminished in size <»r number. If there is a 1 -- 
cell, no matter how small it may be. without a corresponding 
gain in an art of the organ, there will be a loss of function, 

and therefore true atrophy. 

Hypop - is a failure of a body, -ystem. organ, or part to 
dev< - .ndard consistent with the normal, as is sometimes 

- 1 in the sexual organs and large hi — Lb of those anV 

with chlorosis. The brain may show this condition. See Fig. 9.) 

si La understood that a part or portion of a 
part li; - r existed, as in apodia. where the lower limb- are 

_ itallv absent and the - 1 dy is well formed. 

- 



ATROPHY. 



17 



Fig. 9. 




Hypoplasia of the left occipital region in a deaf and dumb person. One-third 
of the natural size. (After Ziegler.) 



Fig. 10. 




G. E. Shoemaker's case of apodia in a girl aged nine. Sitting position. 
{Trans, of the College of Phys., vol. xiv.) 



18 



GENERAL PATHOLOGY. 



Fig. 11. 




Normal position of the thy- 
mus gland in a child aged 
about two years. One-third 
natural size. (After Heitz- 

MANN.) 



The thymus gland (see Fig. 11) is an excellent example of 
physiological atrophy. This gland reaches its full growth at the 

second year of life, and then diminishes 
in size until at puberty it has almost dis- 
appeared. It lies about an inch below the 
thyroid gland, between the apices of the 
lungs, in front of the trachea and the large 
bloodvessels of the heart, and resting upon 
the pericardium. It is about two inches 
long and one and a half inches in breadth. 
Mistakes are frequently made at post-mor- 
tems on children in regard to the location 
of this gland as well as to its nature when 
found. 

A good example of a combination of 
simple and numerical atrophy is to be 
seen in that interesting disease known as 
chronic spinal muscular atrophy : the 
walking skeletons of the dime museums. 
The atrophy of the muscles is due to degenerative changes 
which take place in the large ganglion cells of the anterior 
horns of the spinal cord, associated with a corresponding de- 
generation of the motor nerves which arise in this situation. 
The lateral and pyramidal tracts are usually also affected in the 
late stages of the disease. It occurs three times more frequently 
in males than in females. Nine times out of ten the atrophy starts 
in the arms, either in the muscles of the shoulder or of the hands. 
Death is frequently caused by interference with the muscles of 
respiration. At a post-mortem made at Elwyn on a girl aged 
seventeen, the diaphragm could be plainly seen through, the ten- 
donous portions being much larger than normal, and the whole 
looking like the diaphragm of an infant. The sterno-mastoid 
muscles were unusually prominent, on account of the great emaci- 
ation, though they were no larger than normal in a healthy girl 
-< vcnteen years old. The reaction of degeneration may be present. 
The muscles are pale in color, and may be found with difficulty. 
The muscle fibres may show vitreous and fatty degeneration, nar- 
rowing, and a peculiar longitudinal striatum. The large ganglion 
cells of the anterior horns may be entirely gone or show numerical 
and simple atrophy; those remaining may have lost their pro- 
longation-. 



ATROPHY. 



19 



By active atrophy is meant that the cells are not able to use up all 
or any of the nourishment which is normally offered to them. By pas- 
sive atrophy, that there is a qualitative or quantitative change of the 
nourishing material, or that there is supplied to the cells a substance 
which is injurious to their proper nutrition. For example, if one 
thousand cells have been receiving enough blood to nourish them 
and the amount of blood is diminished in quality or quantity one- 
half, only five hundred cells can be properly nourished. What 
will happen ? The cells will not receive their normal amount of 
nourishment, and probably several hundred will disappear, and 
those which remain will be reduced in size, and the functional 
activity of the part will be lowered. (See Fig. 12.) 



Wk 




Atrophic liver cells from cyanotic atrophy of the liver in different stages of simple 

atrophy. X 400. (Hamilton.) 



In myelitis bed-sores may be produced in four to five days, while 
in lesions of the brain, such as a hemorrhage into the internal 
capsule, the patient may remain in bed for years without the pro- 
duction of bed-sores. This is a tropho-n euro tic form of atrophy, 
and is due to the fact that the trophic nerves which control the 
nutrition of the part have been cut off from communication with 
the spinal cord. Charcot's joints in tabes dorsalis is another ex- 
ample. 



Degenerations. 



Infiltrations {Q^ative, 
(. Quantitative. 



1. Fatty. 

2. Calcareous. 

3. Pigmentary. 

4. Dropsical. 

5. Glycogenic. 

6. Urinary, lactic, etc. 



Metamorphoses or 
degenerations proper. 

1. Fatty. 

2. Amyloid. 

3. Hyaline. 

4. Parenchymatous. 

5. Serous. 

6. Colloid. 



7. Mucoid. 
(The degenerations can be greatly increased in number beyond 
the more important ones mentioned above ) 



20 GENERAL PATHOLOGY. 

By degeneration is understood structural impairment of the cells 
of a tissue, with loss of function. The process is therefore an ele- 
mentary, morbid process, which is retrograde in its nature. Two 
divisions are usually made, namely, into the infiltrations and the 
metamorphoses or degenerations proper, though there is often no 
sharp distinction between them. In an infiltration something is 
always added to the cell from without. This material may be 
foreign to the part, or it may be a normal constituent of the part 
added either in excess (quantitative) or changed in its nature (quali- 
tative). In a metamorphosis we have one or more of the constitu- 
ents of the cell itself being converted into a new material, the change 
often being materially assisted by new matter brought from with- 
out, or a normal constituent of the cell is formed and stored up in 
abnormal quantities in the cell. The blood is the usual agent in 
bringing the new material, though it may gain access to the cell in 
other ways. 

Fatty Infiltration. 
Phys. ex. : Milk. 

Exhibits. 

Slide showing human milk. 

Slide showing cow's milk. 

Slide showing emulsion of cod-liver oil. 

Fatty heart. 

Fat necrosis. 

Epiploicae appendices. 

Fresh specimens. 



Milk is formed by a combination of fatty infiltration and fatty 
degeneration, the albuminates being converted into fat. 

Fatty degeneration is much more serious than fatty infiltration, 
for in infiltration the fat lias been brought from without, and there 
is given an opportunity for the cell to either use up this amount of 
f;ii or to have it absorbed. Therefore, even though the protoplasm 



FATTY INFILTRATION. 



21 



of the cell has been pushed aside, the cell may return to its normal 
state again ; whereas, in degeneration the change has taken place 
in the protoplasm itself. There has been a structural change of the 
protoplasm of the cell, and this is a more serious matter than 
merely pushing it aside. The protoplasm of the cell in fatty infil- 
tration is like an elastic ball, which will rebound when the pressure 
is removed. 

In a normal heart you will always find some epicardial fat in 
the region of the septa. If fatty infiltration be excessive the 
entire heart may be covered with a layer of fat, and the heart itself 
be hid. This fat follows the trabecular of connective tissue into 
the heart muscle, and very frequently, by pressure, fatty degenera- 
tion of the muscle itself may be caused. 



Fig. 13. 




Fatty infiltration of liver cells. X 400. (Hamilton.) 

a, First stage, where the globules are small, b, Second stage, where they have partly run 
together, c, Third stage, where there is a single droplet, d, Fourth stage, where the 
nucleus of the cell has been pushed toward one side and the protoplasm of the cell has been 
distended. 



Fat is normally to be found in many portions of the body, and, 
as would be expected, these situations are the ones in which an 
excessive deposit of fat especially occurs. In the brain, where 
normally there is no fat, we may, however, have a lipoma (a fatty 
tumor). The fat produced in fatty degeneration is frequently de- 
posited in the neighborhood of such a degeneration, as is seen in 
the large amount of fat surrounding certain degenerative changes 
of the kidney. In starvation the fat in Tenon's capsule is the last 
to disappear. On account of the fact that fat is soluble in certain 
of the reagents — chloroform, alcohol, and ether — used in the hard- 
ening of tissues, care must be taken to first thoroughly fix the fat, 
as with Midler's solution, or fix and stain at once with Flemming's 



22 GENERAL PATHOLOGY. 

solution, or better still, prepare a frozen section, cut, and stain with 
a one-half of one per cent, osroic-acid solution. 

Under the microscope (see Fig. 13) the fat droplets are larger 
than in fatty degeneration, and there is a decided tendency for 
them to run together. In the liver it is frequently difficult or 
impossible to tell these conditions apart ; the fat of fatty infiltra- 
tion being, however, brought by the blood, those cells lying nearest 
to the portal blood supply are usually first affected. 

Calcareous Infiltration. 
Phys. ex. : Bone. 

A. 
From within the body. Ex., heart ; osteophyte. 

B. 
From without the body. Ex., anthracosis. 

Exhibits. 

1. Calcareous infiltration of the valves of the heart. 

2. Osteophyte. 

3. Calcareous infiltration of a uterine fibroid ; specimen and 
slide. 

4. Concretions in gout. 

5. Atheromatous bloodvessels, infiltrated with lime. 

6. Calcified tubercle of lung. 

7. Lipoma, undergoing calcareous infiltration. 

8. Slide of encapsulated trichina? spiralis with calcified walls. 

It must be borne in mind that the use of the term calcareous 
infiltration is a general one, and includes other substances, such as 
magnesia, uric acid, coal dust, etc., and that many of these sub- 
stances, such as coal and silver, may give rise at the same time to 
a pigmentary infiltration. 

While it is, of course, distinctly understood that the material 
1 1 1 1 1 — r come from without the cell, it may either come from within 
the body, as in the case of a fractured limb, or from without the 
body, as in siderosis, 

You may find that the parietal pleura, becoming thickened by 



CALCAREOUS INFILTRATION. 23 

inflammation, may become so infiltrated with lime that the impres- 
sions of six or seven ribs are plainly seen in the mass when it is 
removed. 

The lime is usually found in the form of a carbonate and the 
magnesium in the form of a phosphate. Chemical tests will readily 
distinguish the one from the other. There may be an internal, or 
more rarely an external ossifying pachymeningitis, giving rise to 
osteophytes. These are most common in the falx cerebri, and 
sometimes give rise to pressure symptoms. They are especially 
found in old people and in the insane. A remark made by 
Gowers is as applicable here as elsewhere. It is that the patho- 
logical processes are more frequent and varied in the insane than 
in the sane ; but this does not necessarily imply that these lesions 
are the cause of the person's insanity. 

Calcareous infiltration is frequently of use, as is seen in the infil- 
tration of necrotic and fibrous areas, in the tubercle, in the encysted 
trichinae spiralis, in a dead foetus, etc. 

The term anthracosis is one to which many meanings may be 
attached : First, any pigmentation of the lungs with foreign mate- 
rial, such as coal, soot, brickdust, etc., set up by the inhalation of 
the above particles. Second, a disease of the lungs, in which the 
connective changes predominate, caused by the inhalation of coal. 
Third, the growth of the tubercle in such a lung as is described in 
two. The first is preferably called anthracotic pigmentation ; 
the second, anthracosis ; and the last, tubercular anthracosis. 
Normally, a certain amount of anthracotic pigmentation is found 
in the lung. In emphysema and anaemia the dark color is, by con- 
trast, well marked. The particles usually get in, by specific gravity, 
to the dependent portion of the lung ; they are absorbed by the 
lymphatic cells, carried to the glands, and often give an intense 
pigmentation to these glands, the student sometimes mistaking 
these black glands for melanotic sarcomas. The irritation pro- 
duced by these particles gives rise to the formation of connective 
tissue. The vitality of the part is naturally lowered, and in con- 
sequence a more favorable opportunity is given for the rapid growth 
of the tubercle bacilli in case they should gain entrance into the 
lungs. The lungs of any patient who consults you should be care- 
fully examined, if upon inspection of the hands you should discover 
small portions of coal imbedded in the skin. Gunpowder, salts of 
silver, etc., may, under certain conditions, also become imbedded 
in the hands without, of course, gaining entrance to the lungs. 



24 :-svsea: ?a:z::::-t. 

Sideroa? is an injfiltrarion of the longs with steel or iron ; chali- 

?1 "r :i ~ z z : . : -z - ] 1 : z : _ .. z 

J. 
From within the body. Ex.. Addison's disease; melanotie 

^_ 
From without the body. Fx-. argyria. Parasitic Ex., iavus. 

a. Ha?niatnt£enou~ — z . hannoeiderin : haimatoidin : bilirubin : 

_ z-._ 
6. Metabolic. 

1. Recurrent melanotie sarcoma of the stump. 

_ 'Jrystals of ha^natoidin. 

^z .- -z ~:z^ Zizzi z .rzz 
-L Brown atrophj z 

Tatoo markhiz z the skin 
6. Corpus luteum. 

i : t-1 z — izztZ- 



The blood supplies or helps to elaborate the pigment formed 
within the body, and even the hepatogenous or metabolic varieties 
are therefore really derived directly from the blood. The haemo- 
globin is the pigment which gives the red color to the blood. 

Haemoglobin supplies two forms of pigment,, differing in their 
chemical composition and morphology, namely, granular, or, more 
usually, crystalline haematoi izz s^e Plate II.), which does not con- 
tain iron, is soluble in chloroform and ether, insoluble in alcohol, 
and is formed inside of large extravasations of blood, where the 
living cells of the body have not come in contact with the haemo- 



PLATE II. 




A. Hsematoidin crystals from old hemorrhage into brain. X 400. 
(After Hamilton.) 

B. Hsemociderin granules in atrophic liver cells. X 400. (After 
Hamilton.) 

C- Cells from a melanotic sarcoma infiltrated with melanin. X 400. 
(After Hamilton.) 

D. Extraneous pigmentation. Particles of coal and soot from a coal- 
miner's lung, along with some pigmented catarrhal cells. X 400. (After 
Hamilton.) 

E. Teichmann's haematin crystals. X about 400. (After Peyer.) 



To face page 24.] 



SEKOUS INFILTRATION. 25 

globin, and hsemociderin (see Plate II.), which is represented by 
different substances, contains Fe, is usually granular, and is formed 
in the midst of living cells or in their neighborhood. According 
to Schmidt, the hsemociderin is a transition stage, and is found in 
the periphery, while the hsernatoidin is the final product, and is 
found in the inside of the bloody mass. 

In Addison's disease, which can be produced artificially by the 
removal of the adrenals (supra-renals), you have bronzing of the 
skin, due to the deposit of pigment in the epithelial cells and in 
the tissue. 

In argyria there is a discoloration of the skin induced by the 
excessive use of the salts of silver (argentum). This discoloration is 
similar to the appearance given to the skin by the burning in the 
dark of common salt in alcohol. 

Lutein is found in the corpus luteum and in the yelk of the egg. 

In melanotic sarcoma the pigment melanin is to be found. 

In brown atrophy of the heart the cells are atrophied or de- 
stroyed, and the haemoglobin, as a granular material, is deposited 
near the poles of the corpuscle of Schultze. 

Certain medicines are changed in the intestinal canal with the 
production of certain colors ; for example, white subnitrate of bis- 
muth, when acted upon by the sulphuretted hydrogen of the intes- 
tinal tract, is converted into black sulphide of bismuth. When 
using the drug in children always tell the mother or nurse that the 
stools will become black in color, or otherwise she may be greatly 
alarmed by the sudden change in the character of the stools. 

Bilirubin is the chief coloring matter of the bile, and is similar 
in its chemical composition to hsematoidin. 

Dropsical or Serous Infiltration. 
A. General. B. Local. 

Causes: 1. Metabolic. 

2. Changes in bloodvessel walls. 

3. Changes in the composition of the blood. 

* If the fluid contains over 3 per cent, of albumin, or if its 
specific gravity is above 1016, it is of inflammatory origin. 

Exhibits. 

1. Pericardial fluid. 

2. Picture of a patient suffering from anasarca. 



: - i : .- .-. i :- a - z ; : ; :- 7 



z _ ■_-- 

H; : -"-:.-.:■: zzz z::~ i_ ~_z :_t ~-:z-.zz izz 
- V^;--~2i :^3rzii :r : ri_ fiT-;: - - — '. -. .. : ' z . " 
. - : . _ zz- :_: " '. : "z " z 7r • 

when a portion of the bain or cord is destroyed and is not re- 

_— --- i:\zziz_zzi :z ■;■: zz: iz :_t : ■ . _._. . 
_-_- ■ - - - .: : zzi ..- — :: : " _ : ii—i-r . Lzz^rzi 

.: ■ -.". ;-. z z_ : - -: •> ■ ". r zz: "._. : .- — _: _t." ".->".-_- : z zzesE 



-l z r z iz ■ ■ _ . . " : - - : z .._:_. t "-/«_ : 

I": - . - .. z z : — : - z / z„ :_ — - _- : - :^i- 

lulartisso^ or in a serous cavity (Quain). The condition is called — 

H~ !::•.-: zzi - ~zzz zz~ z , : :- iz '—- ir: _z :. ::- 

B " - * : _ • "" " > 

H - i r ■ : r- ■ ii iz :ir »-^ 

Hydrothorax, in the pleura. 

_ . - - v - : . ". z_iz iz — 

Pi- :~zi ::•. :> :z:z- .-__"•: --z: 
Pericardial fl oi«£ 

Peritoneal transudate. 1.11 per cent. ; 
B bentaneoos connective tissue. 0.58 per cent. 
in the dependent portion of the tissue will give a clear 
liquid. Pitting is produced by pressure on the part, the liquid 
which has been expei imniediately returning. 



FATTY DEGENERATION. 27 

(Edema may be — 

Toxic, thermic, traumatic, ischemic, cachectic, etc. 

As long as absorption goes on by the veins and the lymphatics 
usually no excess of fluid will accumulate, but if the outward flow 
is impeded there will be a damming back of the fluid, and the fluid 
will be kept within the tissue. 

Chief Causes : Heart, liver, or kidney disease, the worst cases 
being those in which all three of these important organs are affected. 

Serous infiltration is apt to be first observed in the cellular tissue 
about the eyes, in the feet, or at the junction of the finger and the 
nail in the hand. Putting on the shoes in the morning with ease 
and removing them at night with difficulty will frequently first 
attract the attention of the patient to his condition. * After a rapid 
walk, especially if it be cool, the finger-tips will often reveal the 
presence of serous infiltration. 

Glycogenic Infiltration. 

Glycogen may be deposited in the hepatic and renal cells in 
diabetes. A brown color is given with iodine. 

A number of the normal fluids of the body, such as urine, saliva, 
milk, etc., may, by means of injury and other diseased conditions, 
become infiltrated into the surrounding tissues, and thereby set up 
peculiar degenerative changes. 

Fatty Degeneration. 

Phys. ex. : Uterus after childbirth. 

Cause : Diminished supply of oxygen. 
Ex. : Heart, liver. 

Exhibits. 

1. Fatty degeneration of the heart. 

2. Acute yellow atrophy of the liver. 

3. Chronic parenchymatous nephritis. 

4. Cholesterin plates and margaric acid crystals. 

In fatty degeneration there is a change of the albuminates into 
fat, this chauge often being preceded by one of cloudy swelling. 
The most marked examples of fatty degeneration are to be seen in 
the organs of pernicious anaemia. Here there is a marked diminu- 
tion in the normal supply of oxygen to the parts, on account of the 



28 



GENERAL PATHOLOGY. 



diseased condition of the red blood-corpuseles. Fatty degenera- 
tion is also seen in chloroform narcosis, the degeneration of the 
heart muscle occurring at times in the course of a few hours. 
Artificial fatty degeneration is produced abroad in the livers of 
geese and ducks, for the sake of producing a delicacy known as 
pate de foie gras. It is brought about in these animals by the 
administration of the salts of antimony, by lack of exercise and 
over-feeding. 

The final product of fatty degeneration is frequently cholesterin, 
compound granule cells and crystals of margaric acid — probably 
a mixture of palmatic and stearic acid, but by some recent ob- 
servers supposed to be a definite chemical compound, melting at 
about 60° C. (See Fig. 14.) 

Fig. 14. 




Fat crystals. X 300. (Ziegler.) 

a, Cholesterin plates, b, Tuft of margaric acid crystals, c, Tuft of margaric acid crystals 
enclosed in fat cells, d, Feathers of margaric acid crystals. 

Fat, as it normally exists in the human body, is a mixture of 
olein, palmatin and stearin. Olein is fluid at the ordinary tem- 
perature of the body, while palmatin becomes fluid at 46° C, 
and stearin at 53° C. The cells in fatty degeneration contain 
fat in a more finely divided state than in fatty infiltration, where 
the droplets are apt to run together into one large drop. Fatty 
degeneration follows the administration of a number of poisons, 
such as phosphorus, iodoform, arsenic, sulphuric acid, nitric acid, 
etc. Exhausting disease, such as phthisis, leucocytha?mia, and 
Addison's disease, especially give rise to it. It may follow scarlet 
fever and various other septic conditions. The prolonged use of 
alcohol may also produce it, A nerve, when cut off from its 



AMYLOID DEGENERATION. 29 

trophic centres, undergoes a secondary degeneration, which is really 
nothing more than a fatty degeneration. 

An examination of the muscular papillae of a fatty degenerated 
heart shows numerous small, creamy-colored areas, which stand 
out prominently from the anaemic or reddish-brown areas. This 
has been compared to the variegated appearance of the breast of a 

Fig. 15. 




Fatty degeneration ol musculus papillaris. (Hamilton.) 

thrush or to faded leaves. (See Fig. 15.) In advanced cases, 
however, the degeneration may be so marked that the heart muscle 
is of the color of a fatty liver. In septic conditions small hemor- 
rhages will often be found beneath the epicardium. The heart 
muscle itself is flabby and in some cases very friable. 

Amyloid Degeneration. 

No physiological example. 

1. In liver, spleen, kidney, etc. 

2. In nervous tissue, prostate, etc. 



30 GENERAL PATHOLOGY. 

3. Artificial amyloid reaction. 
Sago spleen. 
Iodine reaction. 

Exhibits. 

1. Amyloid liver. 

2. Section from amyloid liver stained with gentian violet. 

3. Sago spleen. 

4. Sago spleen acted upon by Lugol's solution. 

5. Picture of artificial amyloid degeneration. 

6. Amyloid bodies in prostate. 

Fresh specimens. 



Amyloid degeneration is especially apt to occur in constitutional 
wasting diseases, such as syphilis and tuberculosis, especially if they 
be accompanied by a running sore from a bone lesion. A spleen 
affected with amyloid degeneration is called a sago spleen, because 
the Malpighian bodies are greatly enlarged and stand out promi- 
nently upon the true splenic tissue, looking like boiled sago 
sprinkled on fresh-cut beef. You may have amyloid degeneration 
of the spleen without having the characteristic appearance of the 
sago spleen. There is no such thing, however, as a sago liver or 
kidney. It is at times impossible to detect amyloid degeneration 
in an organ without proper staining. The waxy liver is so called 
on account of its resemblance to smoked ham or salmon, or boiled 
bacon fat. All parts of the organ are equally enlarged ; giving a 
square appearance to the organ. The edges are rounded, though 
not as markedly as in a fatty liver. The capsule is translucent, 
smooth, and thin, the organ seeming to stretch it. To the touch 
the substance is firm and hard, resembling a piece of India-rubber. 
The amyloid liver may reach an enormous size and weigh from 
twelve to sixteen pounds or more. If a nerve tissue, such as a 
spinal cord, be bung up in spirit for any length of time, you may 
have th( production of amyloid bodies which cannot be distin- 
guished from those which occur in certain diseased states. The term 
artificial amyloid has !><< n. therefore, given to this condition, and 



AMYLOID DEGENERATION. 



31 



no doubt many cases which have been described in the nervous sys- 
tem were due to the artificial variety. Amyloid means, like starch, 
because if sulphuric acid be added to these bodies, and then an 
aqueous solution of iodiue, in potassium iodine, a blue color is 
produced. (See Fig. 16.) 

The best test for amyloid degeneration is found in the applica- 
tion of Lugol's solution, which is prepared with one part of iodine, 




Section of an amyloid kidney, treated with Mtiller's fluid, prussic acid, and 
methyl violet, x 300. (Zieglee.) 

a, Normal capillary loop, b, Amyloid capillary loop, c, Fatty epithelium of the glomer. 
ulus. c, Fatty epithelium of the capsule, d, Oil-drops on the capillary wall, e, Fatty 
epithelial cell in situ, f, Loosened fatty epithelial cells, g, Transverse section of a hyaline 
cast, i, Amyloid artery, k, Amyloid capillary. I, Infiltration of connective tissue, with 
leucocytes, m, Round cells (leucocytes) inside a uriniferous tubule. 

two parts of the iodide of potassium, and seventeen parts of water. 
You cut and wash with water a thin strip from the organ to be 
examined, and, placing this strip upon a dish, you cover with water 
and then add a few drops of LugoPs solution at a time until the 
tissue is lightly stained. On examination, by a good light, you 
will find that the portions of the tissue affected with amyloid 
defeneration will have a red mahoojanv-brown coloration entirely 
different from the stain which the iodine will give to the tissue if 
the amyloid degeneration has not taken place. This color is diffi- 
cult to describe, and should be seen to be appreciated. 



32 GENERAL PATHOLOGY. 

Hyaline Degeneration. 
Synonyms : Vitreous, glassy, degeneration. 

Exhibits. 

1. Picture and slide of a small artery affected with hyaline 
degeneration. 

Small arteries, capillaries, and minute veins may form a trans- 
lucent substance closely resembling the material formed by 

Fig. 17. 




Hyaline bloodvessels in a cylindroma. (Ziegler after Sattler.) 
a, Small bloodvessel, b, Patch of epithelial-like cells on one of the hyaline appendages, c. 

amyloid degeneration, but not characterized by its reactions. The 
calibre of the vessels may be diminished, or even obliterated. 

Parenchymatous Degeneration. 
Syn. : Cloudy swelling. 

Exhibits. 

1. Slide of kidney showing cloudy swelling. 

2. Slide of kidney showing the cells acted upon by acetic acid. 

Epithelial cells, which have much to do with secretion and 
excretion, and muscle cells, are especially affected. The soluble 



PARENCHYMATOUS DEGENERATION 



33 



albumin is precipitated in the cell as a finely granular, insoluble 
albuminate, this condition often being the precursor of fatty de- 



FlG. 18. 













Cloudy swelling of renal epithelium. Preparation treated with chromic acid and ammonia. 

X 800. (ZlEGLER.) 

a, Some of the epithelial cells are normal, others show commencing cloudy swelling. 
Remember that normally the epithelial cells are somewhat granular, b, Advanced degen- 
eration, c, Loose degenerate epithelium. 

generation. (See Figs. 18, 19, and 20.) Hyperpyrexia is the chief 
cause, though agents, such as phosphorus, which may produce fatty 



Fig. 19. 



^M s 






a. 

Cloudy swelling of liver cells. 
X 350. (Hamilton.) 




Same treated with acetic acid. 
X 350. (Hamilton.) 



degeneration, can also give rise to this condition. In scarlet fever 
there may be no or little fever, and yet cloudy swelling may be 



34 GENERAL PATHOLOGY. 

produced in the kidney. The cell or fibre becomes swollen, and 
the granular condition may hide the nucleus of a cell or the tissue 
stria?, if it be a muscle. Acetic acid or sodium hydrate will quickly 
dissolve the precipitated material in the cell, and the protoplasm, 
with its nucleus, will again appear clear and transparent. A heart 
affected with cloudy swelling looks like a normal heart viewed 
through smoked or ground-glass. 

It must also be borne in mind that certain methods of prepar- 
ing tissues for microscopic study may either produce or destroy 
this form of degeneration. 

Serous Degeneration. 

This form of degeneration is especially apt to occur in epithelial 
cells and in muscle, when these tissues have been deluged for a 
long time with the modified lymph found in serous infiltration. 
A viscid material collects in the cell, and there is seen a peculiar 
vacuolation of the protoplasm. 

Mucoid Degeneration. 
Phys. ex. : Vitreous humor ; jelly of Wharton. 

Pathologically, this condition is especially apt to occur in con- 
nective tissue. 

Path. ex. : Tumors. 

Myxoedema, cretinism. 

Exhibits. 

1. Myxomatous polyp of the nose. 

2. Picture of a cretin. 

3. Picture of a case of myxoedema. 

4. A fibro-lipoma undergoing myxomatous degeneration. 

In mucoid or myxomatous degeneration you have the for- 
mation of a definite chemical substance known as mucin. This 
substance is in the possession of certain characteristic chemical 
tests, and can be estimated quantitatively. 

Dogs and cats usually live but a short time after the removal of 
the thyroid gland. In man, after the removal of a goitre or 
of the thyroid gland, a peculiar condition known as cachexia 



MUCOID DEGENERATION. 35 

strumipriva is produced. This condition consists in the deposition 
of mucin in the subcutaneous connective tissue and a thickening 
of the integument throughout the body. The features become dull 
and sodden, and the size of the digits is increased. The memory 
becomes poor and mental aberrations may come on. 

It was found that if a portion of the gland was left behind, or 
if there was an accessory gland, this condition did not occur. 

Horsley was the first to suggest that the thyroid gland of an 
animal, such as the sheep, should be either introduced into the 
abdominal cavity or else introduced beneath the skin, when there 
was an absence or had been surgical interference with this 
gland. 

For a short time there followed an amelioration of the physical 
and mental condition of the patient, but soon the gland atrophied 
and the condition of cachexia strumipriva returned. Next an ex- 
tract from the gland was prepared and introduced subcutaneously, 
or the person was fed with specially prepared thyroid glands of the 
lower animals. An amelioration of the symptoms has occurred in 
some cases. 

It would, therefore, seem that the thyroid gland either destroys 
a poison that is circulating in the system, or else that it elabo- 
rates a chemical substance that is necessary for the proper main- 
tenance of health in the body, or to counteract a poison circulating 
in the body. 

Myxoedema is especially found in the Alps, and it has been 
supposed by some observers to be due to the drinking of glacial 
water. This water is of a light-blue color, and the presence of a 
micro-organism has possibly been demonstrated, and this is sup- 
posed by some writers to be the cause of myxoedema and the 
allied condition — cretinism — a congenital form of myxoedema. 

Vaughan has shown from his investigations that an extract of 
the thyroid gland is detrimental to the growth of bacteria. It 
would, therefore, seem probable, or at least possible, that the toxine 
of a micro-organism is rendered inert in the thyroid gland, or else 
that a chemical substance is there formed which is capable of coun- 
teracting the deleterious effects of a poison elaborated by some 
micro-organism or other. 

This form of degeneration appears as a jelly-like substance, even 
more so than in the colloid form of degeneration. 

Fibromas, sarcomas, lipomas, and chondromas are especially 
liable to undergo this form of degeneration. (See Fig. 21.) 



36 



GENERAL PATHOLOGY. 



In a sarcoma which has undergone myxomatous degeneration 
the mucoid material is usually collected in spaces, portions of the 
tumor being unaffected. The connective tissue cells are usually not 



Fig. 21. 




Myxomatous polyp of the nose. The tumor is sessile and very vascular. Pus is running- 
down over the lips, and auto-innoculation is seen on the forehead. (From a wax model in 
the Wistar and Horner Museum.) 

attacked, and can be seen standing out prominently in the jelly-like 
substance ; later on, however, the connective tissue cells themselves 
may become involved. The adventitia of small arteries is espe- 
cially affected. 



Colloid Degeneration. 



Ex. : Cancer. 



Here the cellular structures, especially if epithelial in their 
nature, become converted into a structureless, semi-solid substance 
of homogeneous jelly-like consistency not containing mucin. 

The closure of a duct lined with epithelial cells may lead to 
this condition, as is frequently seen in the kidney. It would seem 
as if the epithelial cells themselves were converted into the colloid 
material. It is so frequently seen in the thyroid gland after forty 
that it cannot be considered as pathological after this age. It is 



NECROSIS. 37 

found in cancerous and cystic ovarian tumors. The chemical com- 
position of the colloid material is very uncertain. 

This form of degeneration may take place in the muscles in 
typhoid fever, the resemblance to the uncooked muscle of fish being 
striking. 

Necrosis. 

I. True : direct, macroscopic. Ex. : Gangrene of foot or arm. 

II. Necrobiosis : indirect, microscopic. Ex. : Pus. 
Terminations : Absorption, retention, thrown off, regeneration, 

cicatrization. 

Line of demarcation. Line of separation. 

I. Coagulation Necrosis. 

Phys. ex. : Coagulation of blood. 
Path. ex. : Diphtheria. 

Diphtheria and true croup have the same cause, but have differ- 
ent anatomical situations. 

II. Liquefaction Necrosis. 
Ex. : Blister. 

III. Cheesy Necrosis, or Caseous Degeneration. 
Ex. : Tuberculosis. 

IV. Gangrene. 

Phys. ex. : Umbilicate cord. 

1. Dry gangrene, or mummification. Arteries affected. 

2. Moist gangrene, or sphacelus. Veins affected. 

Senile gangrene. Raynaud's disease, or symmetrical gangrene. 
Causes. Common : Ergot, diabetes. Pare : Antipyrin, car- 
bolic acid. 

Fresh specimens. 



ExJiizits 
1. I>ry gangrene of the foe 

. : - - " 

4 Diphtherir fen mbrane of the larynx. 

I — -_t:_ : : :.: : . : . - .. . - ~:e-r_. 
Dy^er-Trr: v.i.e:\ 

- Moist ^-angrene of the foot. 

Et-I; living >eli ___>: K'Mr: m lirer -:-- - --:>-. Ir. :_r 
living body cells are constantl y dying and being replaced by cells 
of a like kind. It is only, therefore, when these cells die in 
a" r .'i:rrji" :i:mber» :_;: - ~-_ _;> :_-- -;:_ .:_: :. ::iii:::i : 
necrosis. 

Necrosis is the local death of a cell or of a group of cells in the 
ziiis: :: :~_t i:\^_ ell* : :Lr 1:-1~. 

_ u have t~ varieties. Tz~ zr-:. which is known as true or 
direct, is macroscopic in its nature. This is illustrated by a case 
where we have a large number of cells dying at once, n - seen 
:.i: i^i. z^ei-hir-ii-il. :l_ee_:::~. :Leri;-i :■. ; r_ . ;r_-r_i: :iii e 'r». 

In zeerobk^:- _r indirect form, you have individual cells 

:/:::_ ~-:~-7 T - -~ T ~— ~ "^--e — ^" i-e:eel — ::_ :it :r i_:re ::' 
:i_- t_t^-l" ::■■ rerr :-■:•:.!- r_i;rli; ::r:-;esses. Till- rem is les: 



It may happen that by means of one or other of the degen- 

ive pr« • 9BG£ :he dead cells may be so acted upon and so finely 

divided and emulsified that each individual particle is capable of 

t.:_ : tI__ r : r: :_ :i:e rin-3.T.~.z — l-ere ih-E eli ; Live iiel. Ii: 
formation : > material is known as molecular debris. If the 
~v : L 1. " - - " " : - ■."■.-.- : : : -:_^ .-. :.~ . > :::: -r : .-e 
so acted upon, there may be a reaction in the healthy tissue of such 
an r - :hat a wall may be thrown around the foreign body 
encapsulates it and prevents the dead area from 
being any damage to the living tissue. This wall may afterward 

:. •:_ ■ . .~ • v .. T..i- :- ::.: re :" :-.ri-:e . .".- . ■-:'."-; ir. :. .' -- 
cases where a parasite gains access to the tissue - - -een in the 
of the trichina spiralis, where the vitality of the parasite is such that 
it is capable of living : rs in the tissue without dying 



COAGULATION NECROSIS. 39 

when a large foreign mass, snch as a foetus in the uterus, under- 
goes retrograde changes and becomes necrotic and calcified. 

The foreign body may be thrown off in mass, as is seen some- 
times in a toe or foot becoming gangrenous and separating from 
the body. 

In regeneration, it should be remembered, every cell comes 
from a pre-existing cell, this cell being of a nature similar to the 
one destroyed. If the cell be a simple connective tissue cell its 
place can easily be taken by another cell of a like character. If 
the connective tissue cell is more highly specialized, as is seen in 
the case of bone and cartilage, the cell may be but imperfectly 
formed, as is seen in a chondroma or an osteoma. If, however, the 
cell be a highly specialized one, as in the retina of the eye, Nature 
is unable to produce a cell as good as the one which is destroyed, 
and an inferior cell takes its place ; hence it is that when a large 
portion of an organ has been destroyed, or a number of highly 
specialized cells, we have a connective tissue formation which, as 
age advances, contracts and a cicatrix is produced. 

The line of demarcation is where the battle is going on between 
the dead and the living cells. This line is irregular and is con- 
stantly advancing and receding. This line has a twofold object : 
it may prevent the invasion of detrimental cells, toxines and bac- 
teria into the healthy tissues beyond, or else take part in regenera- 
tion. The line of separation is where the dead tissue is to leave 
the living, and is on the distal side of the line of demarcation, 
occupying the place where the line of demarcation formerly was. 

Coagulation Necrosis. 

A physiological example of coagulation necrosis is seen in the 
coagulation of blood; fibrinogen, fibrino-plastin, and the ferment 
being the prime factors. 

Typical pathological examples of this condition are to be found 
in a diphtheritic membrane and in dysenteric ulcers. In diph- 
theria the pseudo-membrane which is produced on the mucous 
membrane will differ in its macroscopic appearance according to 
its anatomical situation. The tissues of the tonsils, palate, and 
pharynx being softer than of the larynx and trachea, there is given 
a more favorable opportunity for the fibrin to penetrate into the 
surrounding tissue, and for the micro-organisms and their toxic 



40 



GENERAL PATHOLOGY. 



products to thus readily gain access to the system through the 
adjacent lymphatics. (See Fig. 22.) 

It should be remembered that the mucous membrane of the nose, 
the conjunctiva, the urethra, the bladder in exstrophy, etc., may 
become primarily or secondarily affected, and show the diph- 
theritic membrane. The cause of the production of fibrin in 



Fig. 22. 




Pseudo-membrane (diphtheritic) of the epiglottis, vocal cords, and larynx. The calibre 
of the larynx is diminished, and the membrane, composed largely of fibrin, is but slightly 
adherent to the dense tissues beneath. The cause is the Klebs-Loffler bacillus. You might 
not be able to tell tbis membrane in the larynx from that caused by certain poisons or by 
the inhalation of steam. (Drawn from a specimen in the Museum of Morbid Anatomy.) 



diphtheria is the Klebs-Loffler bacillus. A pseudo-membrane in 
the intestinal tract is sometimes called diphtheritic when not due to 
the action of this bacillus. Weigert's special stain for fibrin will 
give a blue color to the fibrin under the microscope. 



GANGRENE. 



41 



Coagulation necrosis is also seen after the ligation of a blood- 
vessel and in embolism. 

Liquefaction Necrosis. 

The protoplasm, but more especially the intercellular substance, 
is converted into a liquid. This condition may either precede or 
follow coagulation necrosis. Familiar examples of liquefaction 
necrosis are seen in the blebs after a burn or after the use of can- 
tharides. Thrombi are largely removed by this process of lique- 
faction necrosis. 

Cheesy Necrosis or Caseous Degeneration. 

By means of a form of fatty degeneration induced by the action 
of certain poisons, especially those elaborated by certain micro- 
organisms, there is produced either a dry or moist form of necrosis 
resembling that seen in coagulation necrosis, but not containing 
fibrin. The dry form is frequently seen in the encysted and calci- 
fied nodules in a tubercular lung ; also in dermoid cysts. One 
form maybe converted into the other. 

Gangrene. 

Among the lower animals the mother may bite off the cord from 
her offspring. This laceration of the bloodvessels produces a coag- 

FlG. 23. 




Hand affected with dry gangrene, showing mummification. 
(Photographed by Dr. Robert Formad, from a specimen in the Wistar and Horner Museum.) 

ulation necrosis inside of the bloodvessels. A line of demarcation 
is quickly produced. The process does not get beyond the living 
cells in the region of the umbilicus if no micro-organisms gain 
access to the part. In a newborn child examine not only for 
signs of inflammation following the vessels going up toward the 
liver, but also down along the course of the hypogastric arteries. 

4 



42 GENERAL PATHOLOGY. 

Dry gangrene is especially apt to occur in those cases where an 
arterial collateral circulation is not capable of establishment, as in 
arterio-fibrosis. (Senile gangrene.) The part resembles the condi- 
tion produced by embalming and age in a mummy. (Fig. 23.) In 
moist gangrene the liquid is prevented from passing out by means 
of pressure on the veius and lymphatics. One form of gangrene 
may pass into another, as is seen where an abrasion of the skin in 
moist gangrene allows the evaporation of the fluid and the dry 
form is produced. The term sequestrum is employed for the 
detached portion of the separated bone. 

Raynaud's disease is due probably to nervous influences. The 
appearance of the extremities is like that seen when a person has 
taken a long walk in the cold and then exposed himself to a warm 
fire. 

The physiological effect of ergot is such that a contraction of 
the arteries follows its use. In France many of the inhabitants 
of entire villages have been affected with gangrene from the use of 
rye bread, due to the sclerotium (spawn) of the claviceps purpurea 
developing within the paleae of the rye. 

When antipyrin was first introduced it was employed in such 
large doses that its haemostatic properties produced gangrene in 
certain cases. Several of the French surgeons have lost their 
fingers from gangrene from the repeated use of strong solutions of 
carbolic acid. 

Local Hypersemia. 

Phys. ex. : Blushing. 

1. Active, congestive or arterial. Higher temperature. 

a. Idiopathic. 

b. Collateral. 

2. Passive, venous or static. Lower temperature. 

(After death may become red, due to oxidation of the 
haemoglobin.) 

3. Post-mortem lividity, or hypostatic congestion. 

a. Pressure dispels color. 

b. Bleeds when cut. 

c. Not elevated above surface. 

d. Depends on position of the body. 

e. Extends over more surface. 

f. Shows frequently a mottled appearance. 



THROMBOSIS, HEMORRHAGE, AND INFARCTS. 43 

Local Anaemia or Ischaemia. 

Artificial ischaemia. 

Difference between thrombosis, thrombus, embolus, and em- 
bolism. 

Thrombosis. 
Varieties of thrombi : 

A. 1. Primary or primitive ; 2. Secondary or produced. 

B. Venous, arterial, cardiac, capillary, lymphatic. 

C. 1. Parietal; 2. Obstructing or obliterating; 3. Valvular; 
4. Channelled. 

D. Septic, marasmic, organization of, calcification of, softening of. 
Clots: 

1. Chicken-fat. 2. Stratified or mottled. 3. Currant-jelly. 

Embolism. 
Varieties of emboli : 

Usually a portion of a thrombus. May have also air, fat, pig- 
ment, micro-organisms, portion of a valve or tumor, etc. 

Hemorrhage. 

1. Arterial. 2. Venous. 3. Capillary. 4. Parenchymatous. 
Hemorrhage from free surfaces: 

a. External. Ex. : Hematuria. 

b. Internal. Ex. : Hsemopericardium. 
Hemorrhage into the tissues : 

a. Petechias. 

b. Hsematoma. 

c. Extravasation. 
Hsemorrhagia per rhexin. 
Hsemorrhagia per diapedesis. 

Hemorrhagic Infarct. 

Anaemic Infarct. 
Fresh specimens. 



i-zy:?.A: ?i:z::::-^ 



r-xhiciTs 



1. Hypostatic congestion of the cadaver. 
_ Thrombosis of the omhflical rebels. 

Thrombus in an aneurismal sac 
-L Chicken-fat clots 
5. Stratified dots 

Currant-jelly ck I - 

Hematoma. 

8. Emboli sni of the brain. 

9. Hemorrhagic infarct of the lung. 
10. .Anaemic infarct of the spleen. 

By local hyperaemia is onderstood that there is an excess of 
blood in any part of the body. A physiological example of this 
condition is seen in the sodden dilatation of the capillaries in 
blushing. After death an extensive hyperemia, plainly visible 
. ::__ lir'-f l_.v _:~": ti:::t." ..:-;."' ••:;:" -r„ Li .^rriiz " .::- :: :_t 
body. This is due to the feet that the bloodvessels- especially the 
arteries and capillaries, have been emptied by the contraction of 
their walls and the pressure brought about by the coagulation of 
certain substances in the tissue in which these vessels run. 

Active hyperaemia consists in an increased amount and an 
accelerated flow of blood by means of the arteries into a part, it 
either being due to the feet that there is an increased blood-pressure 
or a diminished resistance. It is either idiopathic,, where the cause 
lies in the relaxation of the muscular walls of the arteries them- 
selves, or else it is collateral (compensatory), where ana em ia of an 
organ or portion of an organ causes more blood to go to another 
part than normally belongs there. For example, if the right 
renal artery should be pressed upon by a tumor, the kidney on 
this side would become anaemic and an excess of blood would find 
be ^ay into the left kidney, which would then be said to be 
affected with collateral hyperaemia. 

Owing to the met that there is more warm arterial blood in the 
part, the temperature will be higher. This may also be due in 
part to increased chemical and mechanical changes along with 
increased heat dissipation. 

In passive or static hyperaemia the veins are filled with 
venous blood due to the natural lack of elasticity in their walls. 
not being able to overcome a pressure exerted on the veins above. 



POST-MORTEM LIVIDITY. 45 

It should be remembered in this connection that the venous blood 
is capable of being converted into arterial blood when exposed to 
the action of the air. This is frequently seen at a post-mortem 
when you have made a sectiou into an organ such as a passive con- 
gested spleen, and have then allowed the organ to be exposed to 
the air ; the color may quickly change from the purplish hue of 
venous blood to the scarlet hue of arterial blood, due to the oxida- 
tion of the haemoglobin. The temperature is here lowered. 

In post-mortem lividity or hypostatic congestion you have 
a hypersemic condition of the cadaver. It is sometimes necessary to 
distinguish this condition from an extravasation of blood. In hy- 
postatic congestion you will find that pressure will expel the blood 
and the part will bleed when cut. This is not so in extravasation, 
for the blood has coagulated and cannot escape from the part. In 
an extravasation you will find that the part affected is elevated above 
the surrounding part and is not so extensive, neither does it pre- 
sent the mottled appearance so characteristic of cadaveric lividity. 
The best means of telling, however, is the position of the body, 
the blood gravitating toward the depeudent portions of the body, 
those portions where the body rests on the table not being affected. 
Turn the body from its back over on the abdomen and the blood 
will gravitate to this region. 

The use of the word anaemia is one to which many meanings 
have been attached. It denotes a diminution of the amount of 
blood in the entire body when such reduction is below the normal 
of one-thirteenth of the body weight. This condition is better 
known as oligemia. It is also used to denote a condition of the 
blood in which there is a diminution of the number of the red 
blood-cells (oligocythemia) or else an actual diminution in the 
amount of the haemoglobin. 

By ischsemia is understood that there is a diminution of the 
amount of blood in a part or a portion of a part. By artificial 
ischsemia is understood that blood has been removed from the 
part by means of external applications, as seen in the lower limb 
when an Esinarch's bandage has been applied. 

By thrombosis is understood the act or condition of the deposi- 
tion of fibrin in the veins, arteries, capillaries, heart, or lymphatics. 
That which is formed and really seen is known as the thrombus, 
though other elements than fibrin may enter into its composition. 

By embolus is understood the circulation of a foreign material 
in one of the circulatory streams of the body and its lodgment 



46 GENERAL PATHOLOGY. 

in a vessel or part which will not permit of its further passage. 
It does not necessarily follow that the embolus will go in the 
direction of the current ; in the veins a backward flow has been 
observed. An embolus is usually a portion of a thrombus. When 
the embolus has lodged, the obstruction of the vessel and the co- 
existing condition of thrombosis is described as embolism. 

An example will perhaps best make this clear. At a post- 
mortem it was found that fibrin had been deposited iu the left 
auricular appendix ; the act of forming the fibrin is known as 
thrombosis, while that which was formed is the thrombus ; this 
thrombus, in which the presence of micro-organisms was demon- 
strated, had undergone liquefaction necrosis, aud a small portion 
was carried through the auriculo-veutricular opening into the left 
ventricle, from thence into the aorta and then down to the radial 
artery. During the time that it was circulating in the arterial 
stream it was an embolus; as soon as it plugged' up the radial 
artery the condition of embolism was produced by a further 
deposition of fibrin in this situation by means of thrombosis. 
Interference with the arterial blood-supply caused a variety 
of dry gangrene. In the spleen and kidneys emboli plugged up 
terminal arteries and we had hemorrhagic infarcts. 

According to the circulatory stream in the body in which you 
have the deposition of fibrin, the name of venous, arterial, cardiac, 
or lymphatic thrombus is applied. 

A primary or primitive thrombus is one in which the original 
seat of the deposition of fibrin is designated. By a secondary or 
produced thrombus is meant the superaddition of fibrin until the 
first main branching vessel is reached. A rounded end, tapering 
off, usually floats in the stream and may then become attached to 
the wall with the production of a primary thrombus in this situa- 
tion, and the formation of a secondary thrombus to the next 
branching vessel. (See Fig. 24.) 

The parietal thrombus is one in which fibrin is deposited upon 
a portion of the wall of the vessel ; if the vessel be entirely closed 
it is called an obstructing or obliterating thrombus. This condi- 
tion is seen after the ligature of a bloodvessel. 

The valvular thrombus, as the name implies, has a valvular 
arrangement of the thrombus permitting the passage of blood 
when the pressure is increased and hindering its backward flow. 

The channelled thrombus is either a complete parietal thrombus 
or else an obstructing thrombus in which a portion has been re- 



CLOTS. 47 

moved and the stream is able to continue in its onward course. 
(See Fig. 24.) 

A thrombus may organize, the new bloodvessels originating from 
the walls of the vessel in which the thrombus is found, and ex- 
tending by means of capillary loops into the new mass ; calcifica- 
tion may set in or liquefaction necrosis may occur, the latter 
especially if there be septic or micro-organismal invasion. 

In certain weakened states, as from excessive hemorrhage or 
starvation, fibrin may be readily deposited, and we have what is 
known as a marasmic thrombus. 



Fig. 24. 




H. 

A. Primary thrombus. B. Secondary thrombus ; the arrow represents the direction of the 
current. C. Complete or obstructing thrombus. D. Parietal thrombus, longitudinal section. 
E. Parietal thrombus, transverse section. F. Circular thrombus, longitudinal section. G. 
Circular thrombus, transverse section. H. Valvular thrombus. 

Clots are of three kinds, chicken-fat, stratified or mottled, 
and currant-jelly. It is usual to see a combination of all three 
at once; the older the clot the more fibrin it contains and the more 
firmly adherent it is to the vessel wall. Chicken-fat clots are best 
seen in death from croupous pneumonia and in opium poisoning. 

An embolus is most frequently a portion of a thrombus. Air 
may be introduced into a vessel by means of an accident or by 
the hypodermatic needle. In a case of fracture, fat may also 
gain access. A portion of a valve — for example, in ulcerated endo- 
carditis — or a tumor growing into the vessel or from the vessel 
wall, may become an embolus. 

By hemorrhage is understood an escape of blood from the 
heart or the bloodvessels, either externally or into or between the 
tissues (Foster). It may be either arterial, venous, or capillary. 
These names explain themselves. By parenchymatous is under- 
stood a combination of the first three mentioned varieties. 

A hemorrhage may be from a free surface, which is either ex- 



48 GENERAL PATHOLOGY. 

ternal or internal; for example, hematuria, in which the blood 
appears in the urine, having escaped from some point along the 
urinary tract ; epistaxis, where the bleeding is from the mucous 
membrane of the nostrils ; haemoptysis, from the lungs ; hseinat- 
eruesis, vomiting of blood from the stomach ; metrorrhagia, a 
hemorrhage from the uterus not due to the menstrual discharge ; 
menorrhagia, excessive menstrual flow ; vicarious or supplementary 
hemorrhage, a hemorrhage from some portion of the body other 
than the uterus, taking the place in part or wholly of menstrua- 
tion ; post-partum hemorrhage, bleeding after childbirth not due 
to laceration; post-mortem hemorrhage, exudation of blood into 
the surrounding tissues due to the fact that the blood has under- 
gone decomposition. 

A collection of blood from an internal surface into the uterus is 
named haematometra ; into the thorax, hemothorax ; into the 
tunica vaginalis of the testicle, hematocele ; into the pericardium, 
hsemopericardium . 

If the hemorrhage into the tissue be small and the areas well 
circumscribed, they are called petechia? or ecchymoses ; if it forms 
in large amount it is known as a suggillation ; and if a tumor or 
swelling is produced it is called a hematoma. 

The blood may escape by a break in the continuity of the vessel 
wall — hseruorrhagia per rhexin, as is seen in the rupture of a 
cerebral artery in apoplexy. The blood may also gradually 
escape directly through the vessel wall, especially through the 
stomata or openings left by the junction of the endothelial cells 
lining the bloodvessels ; this is called diapedesis. 

By hemorrhagic diathesis or haemophilia is understood the 
peculiar tendency exhibited by some persons to bleed upon the 
slightest provocation; they are familiarly known as "bleeders." 

By infarction is understood the plugging up of a terminal 
bloodvessel in such a manner that there is an extravasation of 
blood, with the surrounding engorgement depending upon such 
obstruction. 

By hemorrhagic infarct is understood the formation of a cone- 
shaped area of bloody infiltration, which upon section is wedge- 
shaped, raised above the surface of the organ with the base toward 
the periphery and the apex toward the entrance of the bloodvessel 
into the organ or part. The area is darker in color than the sur- 
rounding tissue, will frequently sink in water if it be lung, and is 
usually distinctly outlined from the surrounding tissue. The 



INFLAMMATION. 49 

artery affected is usually a terminal one. Hemorrhagic infarcts 
are especially liable to occur in the lungs, spleen, brain, and 
kidneys. (Fig. 25.) 



-u. 






Diagrammatic representation of a recent and old hemorrhagic infarct. 
F. is a terminal vessel in which an embolus has lodged. Notice that the apex is toward 
the point of entrance of the vessel and the base toward the periphery of the organ. If the 
line A . . . D. represents the surface, B . . . C. is elevated above the surface, and while on 
section we have an angular appearance, the pathological condition is really one of a cone. 
In the lower figure M. represents connective tissue contracting and producing a cicatrix, the 
wedge shape no longer being demonstrable. 

By ansemic infarct is understood the recent absence of blood 
in a conical area, or else the absorption and healing of a hemor- 
rhagic infarct. 

Inflammation. 

Source 1. Diseased or dead cells. 

2. Micro-organisms. 
Usual form, combination of 1 and 2. 

The clinical form (pain, redness, swelling, heat, and tendency to 
exudation), practically always due to micro-organisms. 
Result, pus: 
Laudable, sanious, ichorous, muco-pus, sero-pus, etc. 



50 GENERAL PATHOLOGY. 



CHEMOTAXIS. 



Positively chemotactic. 

Bacterial proteids. 
Gluten, etc. 



Negatively chemotactic. 
Leucin. 
Tyrosin, etc. 



Inflammation considered : 

1. Clinically: Causes, symptoms, course, termination, and treat- 

ment. 

2. Pathologically: Phenomena of function, nutrition, forma- 

tion, and destruction. 
The great factor : Cell action. 
Terminations : 

1. Sloughing or gangrene. Macroscopic. 

2. Ulceration. Molecular or microscopic. 

Septicaemia. 1 ™. . -. . 

r > Clinical view. 

Pyaemia. J 



Toxic septicaemia. ) -^ . , n . 

. , . . > Jiixperimental view. 
Bacterial septicaemia. J 

Parenchymatous inflammation. 



Exhibits. 

1 . Cultures of pus-producing micro-organisms : Staphylococcus 
pyogenes aureus. Bacillus pyocyaneus. 

2. Various drawings illustrating inflammation. 

Inflammation is the most important composite pathological 
process which we have to study in morbid anatomy. There is 
hardly a process which starts or ends a pathological change that 
has not inflammation as a factor at some time or other in its course. 
A clear conception of this subject, added to a full knowledge of 
the anatomy of the part and a good understanding of such condi- 
tions as the infiltrations and degenerations, will lead you most 
clearly to comprehend all special pathological changes. 

* " Inflammation is the reaction of the parablastic tissues to the 
action of irritants when the reaction is attended with an over- 
filling of the bloodvessels with blood, a change in their walls, and 
an exclusion from them of a modified plasma and of leucocytes, 
and a proliferation of the connective-tissue cells. These changes 



CHEMOTAXIS. 



51 



have for their object the removal or isolation of the source of 
irritation." 

Sanderson describes inflammation as "a succession of changes 
which occur in a living tissue when it is injured, provided that the 
injury is not of such degree as at once to destroy its structure and 
vitality." 

The source of inflammation is either diseased or dead cells or 
micro-organisms, or else a combination of both. 

That the inflammatory process may be started without the pres- 
ence of micro-organisms is shown, experimentally, when a portion 
of sterilized sponge or lung is introduced under antiseptic precau- 
tions into the abdomen of an animal. In the case of lung tissue, 
this being an organic tissue, we may have the structure entirely 
absorbed and an ordinary inflammatory mass left behind. 

By chemotaxis is understood the property which certain 
chemical substances have of attracting (called positive chemotaxis) 
or repelling (negative chemotaxis) the cells. This is independent 



Fig. 26. 



M 



w& — ^ 



wmwofj 



eu© 



©0 



<ro o® o^o 









S>qO _ > 



COqO 
0©<2C 



Diagrammatic scheme to illustrate chemotaxis. 

Notice that in the figure to the left you would naturally suspect that the leucocytes would 
continue along in the direction of the blood-current indicated by the arrow, but such is not 
the case ; they are attracted toward the positively chemotactic substance in the upper por- 
tion of the connecting tube. 

In the figure to the right, the leucocytes are repelled from the negatively chemotactic sub- 
stance and will escape toward the right and left in the direction of the arrows. 



of any vital force, and a force such as the attraction of gravity is 
capable of being overcome by certain products found in, or elabor- 
ated by, some micro-organism. Fig. 26 will perhaps best explain 
this subject of chemotaxis. 



52 GENERAL PATHOLOGY. 

The clinical form, in which we have pain, redness, swelling, heat. 
and a tendency to exudation (dolor, rubor, tumor, calor of Celsns 
of the first century), is practically always due to micro-organisms 
or their products, and constitutes the variety which is described in 
works on surgery, and is the kind that you will be called upon to 
treat. 

The pain is due to the fact that the exudate causes tension upon 
the terminal ends of the peripheral sensory nerves; the redness is 
due to the increased supply of blood to a part, with a dia- 
pedesis of the red blood-corpuscles ; in cartilage, where there is but 
slight vascularity, there is but slight redness ; the swelling occurs 
because there is more fluid in the part, containing leucocytes, 
micro-organisms and their products, connective-tissue cells, etc. 
The cause of the heat is a debated question ; it is uncertain whether 
it is due to the fact that the arterial blood is there in larger 
quantity, or whether there is an increased chemical and mechanical 
change taking place in the part, or whether we have increased heat 
dissipation, or else a combination of these conditions. There have 
been many experiments made to ascertain the cause of the increased 
temperature, but these experiments seem frequently to contradict 
each other. Where the theories are so numerous one may be quite 
sure that a combination best explains the fact, or else that there is 
no satisfactory explanation for the phenomena. 

We have produced in inflammation a substance known as pus. 
This has been described by various names which it is necessary for 
you to understand. The old idea of a laudable pus is that pus 
which is of a greenish hue, with not a bad odor, and which occurs 
in those cases which are apt to recover and in persons of a good 
constitution. We now know that pus is an unnecessary factor in 
the healing of wounds, and, therefore, there is no such thing as a 
healthy pus. Sanious pus is that form in which blood and pus 
are mixed in varying proportions, from the slightest tinge to that 
in which it is mostly blood. Then we have the ichorous pus — 
which is thin and acrid. We have also the muco-pus and the 
sero-pus, in which we have mucus or serum mixed with the 
pus. 

Chemically, pus may be described as an albuminous fluid of a 
specific gravity varying from 1021 to 1042, containing the peculiar 
constituents of the tissue, whether they be cells, salts, or organic 
substances, with a mixture of leucocytes, micro-organisms, and 
certain chemical by-products, such as peptones, proteid compounds, 



MICRO-ORGANISMS OF INFLAMMATION. 53 

and leucin. (See Woodhead, p. 158.) If you open an acute 
abscess and examine the pus under the microscope, you will 
find a great number of leucocytes, and these leucocytes will be 
practically of one size. There will be a very few cells larger 
than the leucocytes, which are connective-tissue cells. If you 
will examine closely you will find that these leucocytes possess 
amoeboid movement. You will sometimes be able, especially 
on a warm day, to examine the amoeboid movement of the pus 
cells in urine very easily without the aid of a Strieker's warm 
stage. If acetic acid be added to the pus, we shall have a 
clearing up of the protoplasm and the appearance of a number 
of nuclei, showing that at some time or other in the life history 
of the cell, there had been an attempt at multiplication. When 
the pus is first being produced we have a number of micro- 
organisms present; but after a time the micro-organisms become 
rarer, and you should not be disappointed in opening a large 
abscess if you are not able to find any micro-organisms at all. 
You expect to find it loaded with various micro-organisms. But 
the micro-organisms have died, have undergone some form of 
necrosis and have been carried off. This is well illustrated in 
tuberculosis. You might not find the tubercle bacilli in the 
cheesy glands of the neck, even though you should scrape along 
the wall of the pyogenic membrane and should stain for them 
most carefully. How will you therefore demonstrate their pres- 
ence? By taking some of the cheesy material and injecting it 
into a guinea-pig — an animal which is especially susceptible to 
inoculation by tubercular material — and allowing the bacillus to 
develop tuberculosis in the animal so injected. 

What micro-organisms are most frequent in the formation of 
pus? Many have been described. The list is a very long one 
and is steadily increasing. The way to remember them is simply 
to note that the names of such micro-organisms usually have the 
prefix pyo, which means pus ; frequently pyogenes, pus-producing. 
They are also described in accordance with their color — citreus, 
albus, aureus, etc.; and by their shape — streptococcus, cocci in 
chains ; staphylococcus, cocci in bunches like grapes, etc. But not 
all micro-organisms that are thus capable of producing pus have 
the prefix pyo. The bacilli of glanders and tuberculosis are cases 
in point. 

The cholera bacillus does not produce pus. This is important, 
as the anti-vaccine of Haff kine is capable of being introduced into 



54 



GENERAL PATHOLOGY. 



man without fear of producing an abscess; only an indurated 
nodule is sometimes left at the seat of inoculation. 

The source of the cellular element (Fig. 27) in inflammation is 
threefold : the outwandering of the cellular elements of the blood, 
this being preceded by the peripheral drift of the leucocytes ; 2d, 
multiplication of the fixed connective-tissue cells and of the endo- 
thelial cells of the bloodvessels by means of a process of karyo- 



FlG. 27, 




Inflamed omentum from the human subject. (Ziegler.) 
a. Normal fibrous trabecula. 5. Normal endothelium, c. Small artery, d. Vein with white 
blood-cells peripherally disposed, e. White blood-cells migrated or migrating. /. Desqua- 
mated (multinuclear) endothelial cell. g. Desquamated endothelial cells, h. Migrated red 
blood- cells. 



kinesis; and 3d, by the growing of cells or spores not capable of 
being demonstrated by the ordinary means when in a state of rest, 
but being brought into activity bv means of the increased nutrition 
of the part, and the demand made upon the tissue for repair. If 
the leucocytes predominate, the retrograde changes are going on ; 
if the connective-tissue cells predominate, the healing process is 
going on ahead of the destructive process ; the latter cells may 
therefore be looked upon as repair cells. Fig. 28 illustrates the 
formation of the new bloodvessels. 

By pyaemia is understood the circulation of the micro-organisms 
in the blood. By septicaemia that the products elaborated by the 



PYEMIA AND SEPTICEMIA. 



55 



micro-organisms at their scat of entrance circulate in the blood. 
There is often no sharp distinction between these conditions, and 
the use of the term bacterial septicaemia is preferable for the 
first condition and toxic septicaemia for the second. As an 
example we would cite an ordinary boil produced by a pyogenic 
micro-organism where a condition of miliary furunculosis followed. 



Fig. 28. 




/IC.S, - 



Loops of bloodvessels in organizing tissue on a serous surface. X 300. (Woodhead.) 

v. I. Loops of vessels fully formed, the structure of which is very readily observed. 

c. s. Double rows of spindle-shaped connective-tissue cells from which the embryonic 
vessels are formed. Most of these cells are arranged with their long axes at right angles to 
the surface. 

c. I. Large cells met with in all granulation tissue derived from connective-tissue cells. 

r. c. s. Small round cells or leucocytes. 



This is bacterial septicaemia. In tetanus the bacillus grows at the 
seat of inoculation, and the toxine circulates in the system and 
acts specially upon the nerve centres. An interesting fact in this 
connection is that surgeons found, for the prevention of tetanus, 
that wounds of the feet are best treated as open wounds. This is 
due to the fact that the bacillus of tetanus is widely distributed in 
the soil and is an anaerobic micro-organism, and when the wound 
is kept open to the air the bacillus is not capable of multiplying 
at the seat of entrance. 



56 GENERAL PATHOLOGY 



Tuberculosis. 



Bacillus of. Lesions of. 
Fresh specimens. 



Exhibits. 

1. Pure culture of the tubercle bacillus. 

2. Slide (under microscope) showing bacilli taken from the 

above. 

3. Slide (under microscope) showing sputum, containing bacilli, 

stained with carbofuchsin. 

4. Slide (under microscope) showing the bacilli in a giant cell. 

5. Drawing of tubercle bacilli. 

6. Sputum of a tuberculous patient. 

7. Tubercles in the lung. 

8. Miliary tubercles in the lung, spleen, kidney, and liver. 

9. Tuberculosis of the liver of a turkey. 

10. Miliary tuberculosis of the serous coat of intestine, with 

ulcers in the mucous membrane and muscular coat. 

11. General tuberculosis of the dog. 

12. Pearl disease, from a cow. 

The original article of Koch in which he so accurately and 
scientifically described the tubercle bacillus, is to be found in the 
Berliner Hinische Wochenschrift of April 10, 1882. In this 
article he announced his now celebrated postulates, viz., that there 
is found a specific bacillus in tuberculous material which possesses 
characteristic morphological properties, is capable of taking stains 
in a peculiar manner, can be cultivated artificially, and when in- 
oculated into certain animals is capable of producing a similar 
disease to that from which it has been taken, and that the organism 
is again to be found in the new growths so produced. The bacillus 
is a rod-shaped, non-motile bacillus, usually slightly bent upon itself 
at a point beyond the centre, and may contain in the central por- 
tion certain ovoidal spots which do not take the stain readily ; 
these have been supposed, but probably wrongly, to be spores. It 



TUBERCULOSIS. 



57 



is If to 5 microns 1 in length; 0.2 of a micron in breadth. The 
easiest way to remember its length is in connection with the 
diameter of the red blood-corpuscle. It is J to J the diameter of 
the red blood-cell, which in turn is 7 to 8 microns in diameter. 
(See Fig. 29.) 

There is no disease of greater import to the human race than 
the one caused by the tubercle bacillus. It is a common statement, 
and one that is well borne out by the facts, that one-seventh of all 



Fig. 29. 



£. 



r 



I . ■ . f vV- ■--.*-." .■■'.J,-: 







c. 



^Hfe 



t 

Action of tubercle bacilli on a tissue. (Ziegler.) 
a, epithelioidal cell, b, a bloodvessel showing karyokinesis of an endothelial cell (d), and 
outwandering of leucocyte (e). c and/ show karyokinetic changes in the tissue itself, g is 
a tubercle bacillus. No giant cells are to be seen as yet. 

the deaths in this portion of the country can be directly attributed 
to tuberculosis in some form or other. Take for example the 
weekly report of interments for Philadelphia, issued by the Board 
of Health, and see for yourself if it is not so. It is a disease of 
all conditions and ages. Tuberculous lesions are found in about 
70 per cent, of all adult post-mortems where death is not due to 
acute diseases and injuries. This would show that nearly every- 
one living to be forty or fifty years of age, will have had an attack 
of tuberculosis at some time or other in their life, and that this 
disease is frequently self-limited. 

Domestic animals and wild animals in confinement are fre- 
quently affected ; the goat is less so than any other animal. The 
dog is not especially liable to become affected, though it may 
become tubercular — for example, by licking up the sputum from 



1 A micron is the l/1000th part of a millimetre, and is represented by means of the Greek 
letter mu (»). 

5 



58 GENERAL PATHOLOGY. 

a tuberculous master. The lesions here are more like that seen 
in acute sarcoinatosis or carcinomatosis. 

In the lower animals the tendency to fibrous formation and 
calcification is extremely well marked. In cattle it is known as 
pearl disease ; the serous membrane, lymphatic glands, lungs, and 
liver are specially affected ; the mesentery is frequently thickened 
and retracted and filled with rounded masses, translucent, slightly 
grayish, and frequently resembling pearls, both as to color and 
shape. These masses are held together by strong bands of con- 
nective tissue interlacing the nodules. 

There seems to be a direct relation in regard to the number of cases 
of tuberculosis to the distribution of the cow, and of the cow to the 
grass which is necessary for its nutriment. The normal tempera- 
ture of the cow is 38.5° C, or about one degree higher than that 
of the human body. This seems to afford the most favorable 
temperature for the growth of the tubercle bacillus. The great 
milkers such as the Jersey and Guernsey cows are especially apt 
to be tuberculous, the lymph glands being specially affected. 

Some interesting experiments have been performed by Pearson 
and others in regard to the use of tuberculin as a diagnostic agent. 
One of the Trustees of the University discovered by means of the 
physical signs, which are very difficult of demonstration on the 
cow, that some of his fine herd of Jersey cattle were tuberculous. 
Some of the animals were found to be in a condition of advanced 
tuberculosis, and others were suspected of being so. Tuberculin 
was injected, and in all those cases where rise of temperature 
followed, tubercular lesions were discovered at the post-mortem. 
The use of mallein for the diagnosis of glanders in the horse niav 
be mentioned in this connection ; a similar rise in temperature 
follows. The process is rendered, however, much more acute after 
the injection of these diagnostic remedies. 

Tubercle bacilli may be found in milk and in urine. The best 
method of collecting them in these media is by means of the cen- 
trifugal machine used to collect the sediment in urine. If this 
machine is not at hand a conical glass can be employed. They are 
then stained in the usual manner. It is much easier to make an 
emulsion out of a tissue with some clear water and a mortar and 
pestle than it is to attempt to stain the tubercle bacilli in the tissue 
itself. An ordinary microscope having an amplification of 300 
to 350 diameters is all that is necessary for the diagnosing of 
tubercle bacilli when properly stained. 



TUBERCULOSIS 



59 



The bacilli may gain access to the body in various ways : 

1. By inhalation — the most common form. When you have 
finished examining your sputum for tubercle bacilli always 
thoroughly disinfect the dish and destroy the sputum. For this 
purpose pure commercial nitric acid gives the best satisfaction. 
Cornet has shown that the dust taken from a place inhabited by 
tuberculous patients is capable of causing tuberculosis — i. e., it is 
infective. 

2. By food. It is for this reason that tuberculosis of the ali- 
mentary tract is the most common form in children, as they are so 
frequently fed on cow's milk. It requires thorough cooking to 
destroy the tubercle bacilli, notwithstanding the fact that they are 
so difficult to cultivate. 



Fig. 30. 




Longitudinal section of a tubercular ulcer of the ileum, 
m. e. Mucosa, which has given way in several spots. 



X 30. (WOODHEAD.) 



v. Villi, infiltrated and enlarged. 
m. m. Slightly altered muscularis mucosa. 

s.m. c. Submucosa, showing a dilatation of the bloodvessels (g) and tubercular follicles (<). 
r. m. Circular muscular fibres, swollen, enlarged, and degenerating at r. m.' 
I. m. Longitudinal muscular fibres. 

s. Thickened and vascular serous coat, showing miliary tubercles following the course of 
the lymphatics. 



3. By inoculation. In the Jewish ritual of circumcision the 
wound in the child has become infected by the rabbi having a 
tubercular lesion in the mouth. Persons who make many post- 
mortems may inoculate their hands, giving rise to what is known 
as the anatomical wart, which runs a chronic course and discharges 
at irregular intervals a small amount of acrid pus. It is sur- 
rounded with a firm connective-tissue wall, and the feeling is as 
if a splinter was in the hand, the core extending down deeply 
into the tissue. The treatment should consist in removal bv the 



- - "- ". 



nealfcb m good tfner^ is praeiiealljr no danger ©fa gen- 
enl inro&renenlL Tdb^rdfe fcodilli are present^ but in snail 



_ _ : -;• :_ — :':■-: _-l~._~~" -::-;:- ~ :>:: -lz. • :z_ lz _ - .- —-n 
. i z. - z - _ ~ - ~ z _ z. _ • i " - 1_ ._ ". : - - z :z_ iz : zi - "; •! : z : i 
: z -z .1 z_- __- — zzz -;• - 7_— t z •-;- z:-- zz-~ it: :■: :e 
£gand in trEue iBenm near tin? iko-caseai xahre r and in the lednnn,. 
z; z_- :-■"- i zzz ~ z : z_- zz-i - ;: zi- i , ~ --^ ~z — ~~y\ : 
z- z- _-:- zz: : i~ z .- :::«;rzz: z z-"~-i : : zi- 



4L By nmtid rttir- CMIdscai naw been km witfe tbe tubercle 

;: ; . _z . r : zzz: 

5 77 ::___.= 



1. ol CtngeniiaL & JLeq[nir@d. 

fL ol Tne initial feaa ©r eftamew 



II Ondrienaa Mm, or nraegra paten. 

Ex. : Placenta^. Kw^ r brain. 

S. a. S&in diseases. Ex.: Pgwwpm%n&. 
■r t Mlihriw? sear f *.t. : IJhner. 
e. O 1ft mi I nmiliiiii Ex : Femur. 
«L Ulcers off Ae lanrnx. 

J. z- ^ ---:" zz: zzz-zzz-: z 
_._. :. iz : iz 

Iiz':::i 

. !:•_.- li — • : — z: zz_ zz~ .-..". :.. z-zzz : zzz :- 

_ " " • ■ _.-._- z: ~z .__ : . - zaz'.'Z. 

-L Bane<sf a ebiBd sb&wing ostee€>-dnigndEitdb dne to beitsdilfarT 



^ypMHiiEn? nfceraiiem of die larynx. 

— ...-. • z 
7. Drawing ©ff Hn#rhinsma r s needL 

. ;• . - " • • ~ z- 



SYPHILIS. 61 

Fresh specimens. 



There is no doubt that syphilis is due to a specific micro- 
organism, though its nature is not yet known. Several have been 
described, the bacillus discovered by Lustgarten being the earliest* 
This bacillus is very similar to the bacillus of tuberculosis, and is 
considered identical by some observers. The great difficulty of 
really determining whether or not the syphilitic organism is dis- 
covered, is due to the fact that none of the lower animals can be 
inoculated with the disease. There have been, however, persons 
willing to subject themselves to inoculation. Robert Cory, an 
English physician, in order to show the danger of taking even the 
clear lymph of vaccine for purposes of future vaccination from a 
syphilitic child, contracted the disease from inoculating himself 
with such lymph. 

While the actual number of deaths from syphilis is not so great 
as in tuberculosis, the misery and suffering induced by this disease 
is probably greater than by any other. Dr. Osier is very fond of 
advising every student practising medicine to be always on the 
lookout for the lesions caused by the three ancient divinities : 
Mars, the god of War ; Bacchus, the god of Wine ; and Venus, 
the goddess of Love. 

It is only necessary to call your attention to some of the various 
branches of medicine and to name a few examples, in order that 
you may be at once struck with the great importance of the patho- 
logical lesions produced by this disease : 

In Surgery : bone and joint diseases. 

In Medicine : endarteritis and aneurisms. 

In ^Neurology : locomotor ataxia and brain tumors. 

In Obstetrics : abortion. 

In Ophthalmology : keratitis and choroiditis. 

In Paediatrics : hereditary syphilis. 

In Otology : some forms of middle-ear disease. 

In Dentistry: Hutchinson's teeth. 

In Dermatology: pemphigus. 

It is also a striking feature of syphilis that certain drugs are 
able to prevent the retrograde tissue metamorphosis. 



62 GENERAL PATHOLOGY. 

There is but little doubt that the virus of syphilis is either be- 
coming attenuated or that the treatment is more vigorously pushed, 
for the older pathologists described many more syphilitic lesions 
than one is able to find at the post-mortems nowadays. Even in 
a place like Blockley, where one would expect to find many bodies 
containing lesions of this character, but few undoubted specimens 
are found. Among the inhabitants of certain islands and in 
certain tribes of Indians the first arrival of syphilis can be traced, 
and the ravages are something frightful, persons frequently dying 
in the course of several weeks or months after the initial lesion. 

According to Cooper (Quain's Dictionary of Medicine) the virus 
is contained in : 

1. The discharge of the initial lesion. 

2. The secretions of all the secondary eruptive lesions, espe- 

cially of the mucous patch. 

3. The blood during the continuance of the secondary symp- 

toms. 

The lesions of the tertiary and later inherited manifestations are 
non-communicable. 

It is possible for the virus of syphilis to pass through the pla- 
centa, which may be considered as a filter, in either direction; and 
if we call F. father, M. mother, and C. child, the following order 
in which contamination takes place after or during conception is 
aloue conceivable : 

First. Second. Third. 



1. 


F. 


M. 


C. 


Usual form. 


2.. 


F. 


C. 


M. 


Eare. 


3. 


M. 


F. 


C. 


Difficult to conceive of. 


4. 


M. 


C. 


F. 


M. to C. most usual form. 1 


5. 


C. 


M. 


F. 


Difficult to conceive of. 


6. 


c. 


F. 


M. 


Difficult to conceive of. 



It should also be borne in mind that the process may stop at 
any point — for example, a syphilitic father may affect the mother 
and the child escape ; or the father may give syphilis directly to 
his offspring, the mother escaping. In the latter case the mother 
will not contract syphilis by nursing her syphilitic child, whereas 
a healthy wet-nurse would be extremely liable to contract the 
disease. 

1 It should always be remembered that the mother may become syphilitic by other than 
the one by whom she is impregnated, and the child thus contract syphilis. 



SYPHILIS. 



63 



The good that can sometimes be accomplished by the perform- 
ance of autopsies is well shown in this connection. Supposing 
that you are called in to treat a family where repeated abortions 



Fig. 31. 



a> 




Syphilitic osteochondritis. 
a. Diaphysis. b. Epiphysis. 



(Specimen from a babe dying from inherited syphilis.) 

c. Line of ostitis, d. Line of chondritis, e. Line of separa- 
tion of the bone from the cartilage. (Natural size.) 

In the long bones, especially the femur, at the junction of the diaphysis with the epi- 
physis where the bone normally grows, a variety of fatty degeneration |from defective 
nutrition may occur. This can be seen macroscopically as a distinct yellow line between or 
on the bone and cartilage. 

Fig. 32. 




Gumma of the liver. (Drawn from a specimen so diagnosed by the late 
Henry F. Fokmad, M.D.) 

The size may vary from that of a pin-point to a pigeon's egg. The gumma is of a rosy-gray 
color in the fresh state. The centre exudes a well-formed gummy material, and the edges, 
made of connective tissue and containing well-formed bloodvessels frequently showing 
under the microscope a form of endarteritis, merge into the surrounding tissue ; but bands 
of connective tissue can be seen radiating in various directions into the liver substance itself. 
A gumma is apt to be found on the upper surface of the liver near the suspensory ligament. 
A radiating cicatrix dipping down into the liver substance is left on healing. Do not mis- 
take superficial bloodvessels for scars ; these vessels sometimes run for several inches on the 
surface of the liver and branch a number of times. 



64 GENERAL PATHOLOGY. 

have occurred. You make a post-mortem ou a foetus aud fiud a 
lesiou deuotiug syphilitic osteo-chondritis. (See Fig. 31.) You 
immediately put the parents on anti-syphilitic treatment, and thus 
do away with the exciting cause for the abortion. 

Hutchinson's teeth, one of the later manifestations of inherited 
syphilis, consist in a malformation of the teeth, especially showing 
itself in the upper incisors of the secondary teeth. They are peg- 
shape, contain a cup-shaped depression on their free margin, often 
going down into the dentine, and frequently point toward the 
median line instead of being nearly parallel. A still later mani- 
festation of inherited syphilis is sometimes seen in a thickening 
and roughening of the periosteum of the superficial bones, such as 
the tibia. 

Scars found at an autopsy on or above the middle third of the 
anterior part of the leg, and not due to a leg ulcer or accident, fre- 
quently point to a syphilitic origin. Remember, also, that the 
scar of the initial lesion on the genitalia, which, however, presents 
nothing characteristic of this condition, can frequently be demon- 
strated in syphilitic cases. 

For a description of a gumma, see remarks under Fig. 32. 

Glanders. 
Etiology : Bacillus mallei (Loffler, Schutz, Israel). 

Two forms : 

1. Glanders proper (nasal mucous membrane chiefly affected). 

2. Farcy (subcutaneous connective tissue chiefly affected). 

Found in man and animals (especially in the horse). 

Exhibits. 

1. Bacilli stained in tissue. 

2. Specimen of glanders from the nasal mucous membrane of 

a horse. 

3. Farcy bud. 

Glanders is caused by the bacillus mallei, a micro-organism 
very much like the tubercle bacillus but shorter and plumper. 
These bacilli frequently join at acute angles, and thus form Y-like 
figures. Portions, said by some to be spores, do not take the stain. 
They have been found in the blood. Glanders proper is chiefly 



ACTINOMYCOSIS. 



65 



confined to the mucous membranes of the nasal cavities of the 
horse, and man contracts the disease by coming in contact with the 
exudate. Cases are on record in which the hostler contracted the 
disease from washing himself with the same sponge which was 
employed in warm weather for bathing the mouth of the horse. 

The bacillus is a pus-producing micro-organism, and a honey- 
combed appearance is given to the part attacked. The submax- 
illary gland is frequently affected, and metastasis may then take place 
to other organs, especially the lungs and alimentary mucous mem- 
brane, and farcy buds may be found in the subcutaneous connective 
tissue and muscles. These nodules follow the lymphatics and 
give the appearance of a string of beads. In man the disease 
sometimes simulates typhoid fever. The nodules may run a very 
chronic course, appearing in successive crops. They very fre- 
quently break down in the centre. Glanders and actinomycosis 
are not so rare as might be supposed, and one should always be on 
the lookout for these lesions — more especially, however, in those 
who are thrown in contact with the lower animals. 

Actinomycosis. 
Found in animals, especially the graminivora, and in man. 



Exhibits. 

Culture of the ray fungus. 

Slide and drawing of a nodule taken from the tongue of a 

cow. 
Specimen of " lumpy jaw " from a cow. 
Picture of Bodamer's case, from the Trans. Phila. Path 

Soc, vol. xiv. 



Fig. 33. 





Drawing of the ray fungus from Bodamer's case. 



66 



GENERAL PATHOLOGY. 



The question of whether or not the actinomycetes are fungi has 
been much discussed. Isenberg so classifies them. The disease is 



Fig. 34. 




"2* 



Lower jaw of an ox affected with "swelled head." Photographed from the first specimen 
described in this country by Bodamer. 

found, especially in those animals which eat grain. It is stated 
by some laboratory workers that the fungus is found attached 



ACTINOMYCOSIS. 67 

to the barley, corn, or rye, and that it is thus introduced into a 
fissure in the mucous membrane of the animal's mouth. Special 
modes of staining have been suggested, that by the pure archil 
(orseille) or orcein giving the best result by means of a single 
stain. 

Actinomycosis was formerly mistaken for tuberculosis and vari- 
ous bone lesions such as giant-celled sarcomata, osteo-sarcomata, 
etc. The fungus grows in rosette-shaped masses (see Fig. 33), the 

Fig. 35. 




Bodamer's case of actinomycosis. The scar tissue is well shown. The ughly scars left in 
the neck are sometimes due to the ray fungus and not to tuberculosis. 

active, living portion being the centre, while the periphery is 
dead or dying. This is so different from the tubercle, where the 
opposite condition prevails. A round-cell infiltration takes place 
around the mass and serpiginous ulcers form, discharging a muco- 
purulent pus which contains rounded, yellowish, or sulphur-like 
bodies, varying in size from that of a pin-point to that of a good- 
sized pea. These bodies, with the honeycombed appearance of the 
part affected, are diagnostic macroscopically of this disease. These 
yellowish masses can be hardened and stained. The lower and 
upper jaws of cattle (see Fig. 34), with the first part of the 



68 GENERAL PATHOLOGY. 

alimentary tract, are most frequently affected, while in man the 
soft tissues of the face and neck, lungs, and mediastinum become 
diseased. George A. Bodamer, the first in this country to demon- 
strate this condition among the lower animals, showed a patient 
(see Fig. 35) of his, suffering from this disease, to the Philadelphia 
Pathological Society, January 1, 1889. At that time only six cases 
had been observed in man in this country. Actinomycosis has 
been observed as occurring primarily in the vermiform appendix. 
This should be remembered as a rare cause for appendicitis. 

Tumors. 

A tumor is literally a swelling, but the term is more especially 
applied to a new growth, which may be either cystic or solid. 
Synonyms : Neoplasm, hyperplasia, new growth. 

Theories of Tumor Formation. 

Tumor diathesis (Billroth). 

Embryonal or evolutional (Cohnheim). 

Mechanical (Virchow). ' 

Nervous. 

Parasitic. 

For the sake of an example illustrating the different theories of 
tumor formation, let us suppose that a woman, aged forty years, 
living near Buffalo, where cancer is very common, should have 
inherited a weakened constitution from cancer being present in the 
family for many generations. A blow having been received upon 
the breast, some embryonal epithelial tissue was injured, and the 
skin being abraded, a psorosperm gained access to the part. As 
the nervous influence controlling the chest was injured or destroyed 
by the shock of the blow, a cancerous tumor developed in the 
region of the breast. 

Tumors may be described in various ways : 

1. According to shape. 

2. According to malignancy. 

3. According to their embryological prototype. 

1. Shape of Tumors. 

A. 1. Deep-seated. 2. Superficial. 

B. Uniform swelling, flat tabular swelling, tubers, fungoid, 



MALIGNANCY OF TUMORS. 69 

polypoid, papilla, dendritic, mushroom, nodes, sessile, pedunculated, 
cauliflower, etc. 

C. The shape is influenced by: 1. The situation, mechanical 
pressure, etc. 2. The method of growth of a tumor. 

A. Deep-seated : 

1. Uniform swelling: a, glioma; b, goitre; c, lymphoma; 

d, lymphangioma ; e, sarcoma ; /, rhabdomyoma ; g, lympho- 
sarcoma. 

2. Nodes growing centrally : a, fibroma ; b, myoma ; c, myo- 
fibroma ; c?, myxoma ; e, adenoma ; /, osteoma ; g, chondroma ; 
h, secondary cancer and sarcoma. 

3. Nodes growing peripherally : a, primary sarcoma ; b, primary 
carcinoma. 

4. Cysts.: a, retention; b, extravasation; c, exudation (as 
ovarian and parovarian) ; d, softening ; e, parasitic ; /, dermoid. 

B. Tumors on the surface : 

1 . Flat tabular swelling : a, keloid ; b, angioma ; c, lymphan- 
gioma ; d, squamous epithelioma ; e, cholesteatoma ; /, sarcoma ot 
serous membranes. 

2. Tubers (a partly projecting node) : a, osteoma ; b, chondroma ; 
c, osteoid-chondroma ; d, giant-cell sarcoma. 

3. Fungus (fungus hsematoides) : a, soft cancer ; b, telangi- 
ectatic sarcoma ; c, cavernous angioma. 

4. Polyps : a, myxoma ; b, soft fibroma ; c, lipoma ; d, adenoma ; 

e, sarcoma of serous sacs. 

5. Dentritic : a, warts ; b, papilloma ; c, epithelioma. 

6. Papillae : a, horns ; b, corns ; c, condyloma. 

2. Malignancy of Tumors. 

By malignancy is understood that a tumor is in the possession 
of one or more of the following properties : 

1 . Recurrence ; after the tumor has been removed it will be 
found after a certain length of time to again appear. 

2. Metastasis ; one or more of the constituent elements of the 
tumor is carried from one part of the body to another, and there 
gives rise to the same kind of growth as the one from which the 
tumor sprang. 

3. Infiltration and destruction of the surrounding tissue. 



70 



GENERAL PATHOLOGY. 



MACROSCOPIC TABLE OF DIFFERENCES BETWEEN BENIGN AND 
MALIGNANT TUMORS. 1 



Benign Tumors 

1. Are homologous and typical. 

2. Are rich in fibres and poor in 

cells. Cells are large. 

3. Grow centrally and compara- 

tively slowly. 

4. Have a capsule. 

-5. Are usually poor in blood- 
vessels, except angioma. 

6. Are usually fair in consistence 

and dry, except myxoma. 

7. Seldom ulcerate, except lipoma. 

8. May grow large and grow up- 

ward. 

9. May be primarily multiple. 

10. Do not recur after removal. 

11. Give no metastasis. 

12. No cachexia. 



13. May kill mechanically by 

weight, pressure, hemorrhage, 
etc. 

14. Prone to calcareous infiltration 

and fatty degeneration. 



Malignant Tumors 

1. Are heterologous and atypical. 

2. Are poor in fibres and rich in 

cells. Cells are small. 

3. Grow peripherally and com- 

paratively fast. 

4. Are not encapsulated. 

5. Are rich in bloodvessels, except 

hard cancer. 

6. Are soft and juicy. 

7. Often ulcerate in tumor itself. 

8. Seldom grow large, except sar- 

coma springing from bone. 
Grow principally downward. 

9. Never primarily multiple, ex- 

cept melanotic sarcoma. 

10. Do recur after removal. 

11. May give metastasis. 

12. Cancer gives a cachexia, espe- 

cially when metastasis has 
taken place. 

13. Kill by infiltration and destruc- 

tion of the surrounding tissues. 

14. Prone to colloid and telangiec- 

tatic changes. 



Xo age is exempt from tumors; but cancers usually occur after 
middle life. 

The situation of a tumor often gives valuable information as to 
whether it is benign or malignant. 

The situation of a tumor may make a benign tumor malignant, 
or a malignant tumor harmless if the proper surgical interference 
be taken. 

It is of course understood that the above statements are not to 
be considered as dogmatic. When taken together, even without a 
microscopic examination, they furnish strong evidence of whether 
or not the tumor is benign or malignant. 

The chief desire of a patient is to know whether or not a tumor 



1 This table and the one on sarcoma and cancer are based largely upon the work of the late 
Henrv F. Formad. 



EMBRYOLOGICAL CLASSIFICATION OF TUMORS. 71 

is malignant, and the intelligent physician will seek to answer this 
question by every means in his power. 

3. Embryological Classification of Tumors. 

This is the scientific method of studying tumors, and is the one 
that is usually adopted for purposes of study. 
Tumors may be divided into 

A. 

*1. Parablastomata or connective-tissue tumors. 

2. Archiblastomata or parenchymatous tumors. 

3. Teratomata or mixed tumors. 

B. 

According to AYoodhead : 

1 . Simple or histioid tumors (composed of one kind of tissue). 

2. Sarcomatous tumors. 

3. Cancerous. 

a 

According to Sutton, tumors are conveniently arranged into four 
main groups, each group containing several genera, each genus 
having one or more species, and of each species there may be one 
or more varieties. The groups are : 
I. Connective-tissue tumors. 
II. Epithelial tumors. 
III. Dermoids. 
IY. Cysts. 

I. CONNECTIVE-TISSUE TUMORS. 

Genera. Species. 

1. Lipomata (fatty tumors). 1. Subcutaneous. 2. Subserous. 3. 

Subsynovial. 4. Submucous. 
5. Inter-muscular. 6. Intra- 
muscular. 7. Periosteal. 8. 
Meningeal. 

% Chondromata (cartilage tumors). 1. Chondromata. 2. Ecchondroses. 

3. Loose cartilages in joints. 

3. Osteomata (osseous tumors). 1. The compact or ivory osteoma. 

2. The cancellous osteoma. 



72 



GENERAL PATHOLOGY. 



Genera. 
4. Odontomata (tooth tumors). 



5. Fibromata (fibrous tumors). 



6. Myxomata. 



7. Gliomata (neuroglia tumors). 

8. Sarcomata. 



9. Myomata (muscle tumors). 



10. Neuromata (tumors on nerves). 



11. Angiomata (tumors composed 

of bloodvessels). 

12. Lymphangiomata (tumors of 

lymphatic vessels). 



Species. 
1. Epithelial odontome, from the 
enamel organ. 2. Follicular 
odontome ; 3. Fibrous odon- 
tome ; 4. Cementome ; 5. Com- 
pound follicular odontome : 

2, 3, 4 and 5 are from the tooth 
follicle. 6. Eadicular odon- 
tome: from the papilla. 7. 
Composite odontome : from the 
whole germ. 

1. Simple fibromata. 2. Molluscum 
fibrosum (include here keloid). 

3. Neuro-fibromata. 

1. Nasal and aural polypi. 2. Cu- 
taneous myxomata. 3. Neuro- 
myxomata. 

Found in brain, cord and retina. 

1. Bound-celled sarcoma (small and 
large). 2. Lympho-sarcoma. 3. 
Spindle-celled sarcoma (small 
and large). 4. Myeloid or 
giant-celled. 5. Alveolar. 6. 
Melanotic. The relative malig- 
nancy of the sarcomata being 
as follows : 1st. Lympho- 
sarcoma, small round-celled 
sarcomata, melanotic, spindle- 
celled myo-sarcoma, spindle- 
celled chondro-sarcoma, mye- 
loid sarcoma. 

1. Leiomyomata (rhabdo-myomata, 
considered by Sutton as a 
variety of the spindle-celled 
sarcoma). Met with in the 
uterus, broad ligament, ovary, 
ovarian ligament, round liga- 
ment of the uterus, vagina, 
oesophagus, stomach, intestine, 
scrotum, skin, bladder, and 
prostate. 

1. Neuro-fibromata. 2. Plexiform 
neuromata. 3. Traumatic neu- 
roma. 

1. Simple nsevus. 2. Cavernous 
nsevus. 3. Plexiform angi- 
oma. 

1. Lymphatic nsevus. 2. Cavern- 
ous lymphangioma. 3. Lym- 
phatic cyst. 



THEORY OF TUMOR FORMATION. 



73 



II. EPITHELIAL TUMORS. 





Genera. 


Spt 
[ Skin Warts. 


icies. 






J Villous papillomata. 


1. 


Papillomata 


j Intra-cystic warts. 






i Psammomata 








f Sebaceous horns. 






J Wart horns. 




2. 


Cutaneous horns . . . . ■ 


| Cicatricial horns. 






! Nail horns. 




3. 


Epithelioma .... 


Epithelioma. 








C Mammary. 


Renal. 






| Sebaceous. 


Ovarian. 






j Thyroid. 


Testicular. 


4. 


Adenoma 


Pituitary. 


Gastric. 






1 Prostatic. 


Intestinal. 






1 

| Parotid. 


Fallopian. 






1 Hepatic. 


Uterine. 






f Mammary. 
Sebaceous. 


Renal. 






Ovarian. 






Thyroid. 


Testicular. 


5. 


Carcinoma (cancer) . 


Prostatic. 


Gastric. 






Parotid. 


Intestinal. 






Pancreatic. 


Fallopian. 






. Hepatic. 


Uterine. 




III. DERMC 


)IDS. 






Genera. 






1. 


Sequestration dermoids. 






2. 


Tubulo-dermoids. 






3. 
4. 


Ovarian dermoids. 
Dermoid patches. 

IV. CYS1 


rs. 






Genera. 


Spe 
Hydrometra. 


ties. 


1. 


Retention cysts . 


Hydrosalpinx. 






v 


Hydronephrosis. 






Hydrocholecyst. 






Vitello-intestinal. 






Allantoic (urachal). 






Paroophoritic. 




2. 


Tubulo-cysts \ 


Parovarian. 






Cysts of Gartner's duct. 






Cystic disease of testis. 






Encysted hydrocele of testis 






L Cysts of Miiller's duct. 



74 GENERAL PATHOLOGY. 

Genera. Species. 

{ Of the tunica vaginalis. 

J Of the canal of Nuck. 

3. Hydroceles - Qf ^ oyary 

I Of the neck. 

Banulae. 
_, _ Pancreatic cysts. 

4. Gland cysts "Chyle-cysts/ 

\ Dacryops. 

There are conditions often classed as cysts which are arranged 
in a sub-group entitled pseudo-cyst- : 

1. DiTerticula Intestinal ; vesical ; pharyngeal ; 

oesophageal ; tracheal ; synovial ; 
meningeal. 

2. Bursas Bursa. 

3. Xeural cysts . . . . Hydrocephalus; hydrocele of fourth 

ventricle ; meningocele (cranial) ; 
spina bifida. 

4. Parasites Hydatids. 

Liponiata. 1 

Exhibits. 

1. Lipoma of the intestine. 

2. Lipoma of the thigh, in which calcareous infiltration has 

taken place. 
Slide of a lipoma. 
4. Slide of a lipo-sarcoma 2 of the adrenal. 

Fresh specimens. 



Lipomata most frequently grow in tho^e situations where 
normally there is fat. exceptions being found, as in the brain and 
the submucous ti-sue of the intestine. They may be single or 

3 The student must not get confused with the word lipaemia— fat in the blood. 

may be well to mention here that the tumor which predominates has the last place in 
a compound-word describing a tumor made up of more than one tissue. 



76 GENERAL PATHOLOGY. 

seen in combination with osteoma. This class of tumor frequently 
favors the embryonic theory, as Virchow has shown that islands 
of cartilage are often to be found in the bones, especially of rickety 
children^ They are especially seen springing from the periosteum 
of bones, those of the metacarpal bones being a favorite seat (see 
Plate III., showing Whittaker's case of multiple osteo-ecchon- 
dromata). They are found in the testicle, skin, lung, breast, etc. 
In the testicle and the parotid gland they are sometimes seen as a 
congenital tumor, and are here frequently in combination with other 
tumors as osteoma and sarcoma (myxochondro-adenoma). 

Macroscopically they are firm elastic tumors, cutting with the 
peculiar creak of cartilage, and in color resemble the boiled white of 
an egg or the inside of an oyster-shell. If mucoid degeneration 
has taken place they may be soft and gelatinous. They are encap- 
sulated and appear as rounded or lobulated masses, separated by 
fibrous tissue containing the bloodvessels. 

Microscopically, the appearance. of the field is that of cartilage, 
though the cells present more irregularity : in shape, in being found 
with and without capsular walls, and in their arrangement. All 
kinds of cartilage from the white fibrous to the hyaline forms are 
found (Woodhead). True bone formation may occur or calcareous 
infiltration alone may take place. 

Osteomata. 

Exhibits. 

1. Osteo-sarcoma. 

2. Odontoma. 

The chief seat for bony tumors is between the bone and its 
cartilage, and they are really ossifying chondromata. An exostosis 
should not truly be classed as a tumor. There are three kinds : 
eburnated (like ivory), compact, and spongy. 

In the eburnated variety the growths may be single or multiple. 
The lamellae follow the outline of the tumor and contain no blood- 
vessels or Haversian canals, though canaliculi are found. 

The compact osteoma may be found in the meninges of the brain, 
choroid of the eye, in the pericardium, etc. The vessels and 
Haversian canals run at right angles to the long axis of the bone. 

In the spongy form Haversian systems are seen, and the char- 
acter of the growth is like that seen on the extremities of the long 
bones. 




Fig. 1.— Anterior view of case of multiple osteo-ecchondroma. 




Fig. 2.— Posterior view of the same case. 



FIBROMATA. 77 

The odontoma ta (see page 72) may be classified here. They are 
no doubt often mistaken for osteomata. 



Fibromata. 

Exhibits. 

1. Inter-, intra-, and extra-mural uterine fibromata. 

2. Calcareous, myxomatous myo-fibroma of the uterus. 

3. Pendulous fibroma of the vulva. 

4. Keloid. 

5. Slides showing fibromata : a, hard ; b, soft ; c, undergoing 
calcification. 

Fibromata are slow-growing, non-malignant tumors composed 
* of fibrous tissue and usually originating in those situations where 
normally fibrous tissue is to be found. The younger the form of 
connective tissue the more apt are they to return if improperly 
removed. Fibromata do not give metastasis, though they are fre- 
quently found multiple upon the skin as in the fibroma molluscum. 
Yellow elastic tissue does not form a tumor ; it is the white fibrous 
tissue from which the tumor originates and of which it is com- 
posed. If they grow from the mucous membrane they frequently 
become ©edematous, and it is sometimes difficult or impossible to 
state whether a fibroma of the nose has undergone myxomatous 
change or whether it is a mucoid polyp. 

There are two kinds, fasciculated and lamellar or flat fibroma. 
Macroscopically the fasciculated, which is the one commonly met 
with, is seen as a firm, dry, glistening, whitish or grayish tumor, 
spots of myxomatous softening with hemorrhages frequently being 
discovered upon the cut surface. It is rounded, usually lobulated, 
and has a capsule. Each lobule is composed of concentric layers of 
fibrous tissue. They seem to grow from their centre and show a 
looser form of connective tissue in which are to be found the blood- 
vessels. 

Two kinds are described according to the sense of touch, namely, 
that of soft or hard. Under the microscope this distinction is dis- 
covered to depend upon whether there are many cells or much 
development of fibrous bands. Picric acid stains fibrous tissue a 
characteristic pink color, and is therefore used in diagnosing this 
tissue from the myoma. (It is very difficult to distinguish under 
the microscope a myoma, a slowly growing spindle-celled sarcoma, 



78 GENERAL PATHOLOGY. 

and a pure fibroma.) These tumors reach an enormous size, are 
apt to become cystic, or fatty degeneration, hemorrhages, and calci- 
fication may occur. 

The flat fibroma is frequently merely an overgrowth of the 
connective tissue enclosing an organ, as in the spleen or pleura; 
they are usually yellow, translucent, and cut with great difficulty. 
Keloids occur especially as an overgrowth of scar tissue in the 
colored race. 

Myxomata. 

Exhibits. 

1. Xasal and aural polyps. 

2. Slide showing the branching and interlacing cells. 

3. Myxomatous polypi from the mesentery of a hog. 

The tissue here is the same as that seen surrounding the vessels 
in the umbilical cord. The sessile myxoma is sometimes in com- 
bination with a sarcoma, and, therefore, recurrence may be found 
(sarcoma myxomatodes). For an illustration of a nasal polyp, see 
Fig. 21, page 36. 

Gliomata. 

Fresh specimens. 



Exhibits. 

1. Glioma of the cerebellum. 

2. Slide from a glioma. 

A great deal of confusion is occasioned in the use of the word 
glioma, some holding it to be merely a variety of sarcoma. This 
occurs from the fact that histologists are not certain as to the 
origin of the neuroglia of the nervous system. It is usually 
found in early life, and there is a gradual replacement of the 
nervous tissue by means of the neoplasm, the difference in color 
and consistence often being but slight ; the tumor is, however, 
usually slightly darker and harder than the brain or cord, the 
color depending largely on its vascularity. The tumor is made 
up of neuroglia cells, the intra-nuclear plexus of the nucleus and 



SARCOMATA. 



79 



the branching processes being easily observed under the microscope. 
Bloodvessels, often numerous, are to be seen running in and out 



Fig. 36. 




Gliomatous tumor of the brain from a boy. X 175. (Hamilton.) 
a. Bloodvessel, b. Spider cell with double nucleus, c. Small round cell. 

among these cells (see Fig. 36). In an autopsy at Elwyn, the 
writer found some forty or fifty of these gliomatous masses scat- 
tered throughout the brain of an idiot. 

Sarcomata. 



Exhibits. 

1. Recurrent large round-cell sarcoma of the elbow. 

2. Myeloid sarcoma of the knee. 

3. Sarcoma of the shoulder. 

4. Recurrent melanotic sarcoma of the stump. 

5. Melanotic sarcoma of the heart ; metastasis from the lungs. 

6. Spindle-cell sarcoma of the eye. 

7. Various microscopic slides from the above. 

A sarcoma is composed of embryonic connective tissue, and is, 
therefore, made up of mesoblastic (parablastic) tissue in an imper- 
fect state of development. An abortive attempt is frequently 
made to reproduce other varieties of connective-tissue cells, such as 



80 



GENERAL PATHOLOGY 



those of fibrous tissue, bone, cartilage, etc. For the varieties see 
page 72. 

Remember that it is often impossible to tell ordinary granulation 
tissue from a sarcoma. If there be no landmarks by means of which 
you can tell, the pathologist should always demand the exact situa- 
tion from which the tumor was removed, age of the patient, sex, 
etc., before making a diagnosis. A case in point well illustrates the 
danger of not knowing all about a tumor before making a diagnosis. 
A prominent pathologist was once sent a portion of tissue from 
the neighborhood of the buttock and was told that it was a portion 
of a tumor. The diagnosis of sarcoma was made, the limb was 



Fig. 37. 




Sarcoma of the dura. 
(From a patient of Dr. Sinkler in the Philadelphia Hospital 



Post-mortem by the author. 
International Medical Magazine, November, 1892.) 



amputated, and the patient lost his life. At the post-mortem it 
was found that the tumor was composed of lipomatous tissue, and 
that the piece sent for diagnosis had been removed from an ulcer- 
ating surface, which would, of course, show granulation tissue. 

Physicians often expect more from the pathologist than they 
should, even going so far as to refuse to tell from what part of the 
body the tumor comes, or of telling the age, etc. Under such cir- 
cumstances the pathologist should absolutely refuse to give an 
opinion, for at the best the physician has the more favorable oppor- 
tunity of casting the blame upon the pathologist, as later develop- 
ments will often prove the correctness or incorrectness of a 
pathological diagnosis when the specimen is in your hand. Per 



SARCOMATA. 

Fig. 3S. 



81 



rf-s V 




Myeloid or giant-cell sarcoma. X 300. (Woodhead.) 

a. Spindle cells of which the tumor is principally composed, b. Cells arranged to form the 
walls of embryonic bloodvessels, c. Giant cell, with large number of nuclei scattered 
throughout its protoplasm, d. Transverse section of spindle cells appearing as round cells. 
e. Extra vasated red blood-corpuscles. 



Fig. 39. 



jj^w^ 




Sarcoma of the shoulder, springing in part from the scapula, but originating in the skin 
over tbe clavicle. The thickening of the skin of the arm was congenital. Metastasis to lungs. 
Point at top of tumor shows ulceration. From the shape the tumor might easily be a lipoma. 
(Specimen No. 92 of New York Hospital. Drawing from a cast in the Wistar Museum, Uni- 
versity of Pennsylvania.) 



82 



GENERAL PATHOLOGY. 



contra, at a post-mortem, unless gross carelessness is discovered, 
the pathologist should never blame the clinician for mistakes in 
diagnosis. 

Fig. 40. 



■ v :•'"■ '-;.','■.'•* 



Dr. C. A. Oliver's case of spindle-cell sarcoma of the choroid, showing a mushroom-like 
tumor. (From a photograph by the author. University Medical Magazine, December, 1893.) 



TABLE OF DIFFERENCES BETWEEN SARCOMATA AND CARCINOMATA. 



Sarcomata. 

1. Are of a connective-tissue type 

and are composed nearly 
entirely of cells embodied in 
a homogeneous or reticular 
matter. Rarely forms alveoli. 

2. Cells endothelial, embryonal, 

or lymphoid. 

3. Acetic acid and caustic potash 

almost dissolve them. 

4. Have bloodvessels without mus- 

cular walls, and running free 
between the cells. Small 
hemorrhages common. 

5. No fat within tumor proper. 



6. Metastasis by the bloodvessels. 



7. May affect lymph glands pri- 

marily, but not by metastasis. 

8. Develop in connective-tissue 

substance. Deep-seated and 
grow upward. 

9. Skin not adherent. 



Carcinomata. 

1. Are of both a connective-tissue 

and epithelial type, and are 
composed of cells lying free 
in the alveolar spaces formed 
by pre-existing connective 
tissue. 

2. Cells exclusively epithelial. 

Distinct nuclei and nucleoli. 

3. Acetic acid and caustic potash 

have no effect. 

4. True bloodvessels and also 

nerves running only through 
the connective-tissue frame- 
work. 

5. Fat may be seen within the 

cancer tissue. Rarely encap- 
sulated. 

6. Metastasis by the lymphatics, 

though in later stages may 
spread with great rapidity by 
the bloodvessels. 

7. Do not develop in lymph glands 

primarily, but often affect 
them by metastasis. 

8. Develop from epithelium. Usu- 

ally peripheral and grow 
downward. 

9. Skin frequently adherent. 



MYOMATA. 83 

Sarcomata. Carcinomata. 

10. Not usually painful. 10. Painful. 

11. Grow in young well-nourished 11. Grow chiefly after middle life. 

individuals chiefly. 

12. Not hereditary. 12. Often hereditary. 

13. Grow rapidly. 13. Grow slowly. 

14. No micro-organism yet de- 14. Due (?) to the psorosperm. 

scribed. 

15. Juice absent or seen some hours 15. Juice can be expelled. 

after removal. 

16. Flesh-like, rounded, and regular 16. Nodular and irregular, often 

masses. On section, smooth ulcerating surface. On sec- 
pearly surface, often of a tion, more granules are 
reddish tinge. opaque, less reddish. 

17. Infiltration of surrounding tissue 17. The malignancy of cancer is 

when present is best seen greater than that of sarcoma, 

with the microscope. the growth infiltrating into 

the surrounding tissue. 

The illustrations (Figs. 37, 38, 39, and 40) show a few of 
the many varieties and shapes seen in sarcomata. 

Myomata. 
Fresh specimens. 



Exhibits. 

1. Myoma of the uterus. 

2. Bbabdo-myonia of the kidney. 

A myoma is made up of muscular tissue, and, as this is of two 
kinds, we have the leio-myoma and rhabdo-myoma, the latter 
being usually a congenital tumor and rather belonging to the 
higher development of a tissue of the sarcomatous type. A myoma 
of the uterus is frequently spoken of as a uterine fibroid, and may 
be intra-mural, submucous, or subserous. In the intestinal tract, 
and often elsewhere, it is usually pedunculated. A 40 per cent, 
solution of caustic potash may be employed for differentiating the 
non-striped muscular tissue from fibrous tissue. When a portion 
of the tumor is placed in this solution for a space of time varying 
from twenty minutes to an hour, the fibrous tissue disappears after 
swelling up, the rod-shaped nuclei of the muscle cells appearing 
in a striking manner. They may undergo mucoid degeneration, 
fatty metamorphosis, calcification, septic infection, etc. 



84 



GENERAL PATHOLOGY. 



Neuromata. 

Exhibit. 

1. Neuroma of a large nerve in a stump. 

This tumor is usually an overgrowth of the connective tissue of 
the nerve, though it may be composed of nerve fibrils or ganglion 
cells, as in the adrenal. (See Fig. 41.) 



Fig. 41. 




False neuroma of the stump of the arm. Case of Dr. W. G. Porter in the 
Presbyterian Hospital. (Natural size.) 



Angiomata. 



Exhibits. 
1. Cavernous angioma of the liver. 



2. Naevus. 

Angiomata are of two kinds : telangiectatic and cavernous. In 
the first variety there is merely an overgrowth of the normal capil- 



FlG. 42. 




Section of a simple hypertrophic angioma of the skin, the duct of a sweat gland being 
shown in the centre of the drawing, x 200. (Ziegler.) 



laries. These may be observed almost any day upon the street as 
large, .slightly elevated, purplish-red patches upon the face (see 



EPITHELIAL TUMORS. 85 

Fig. 42). In early life they may be frequently seen as spiderweb- 
shaped masses, which, later on, for some reason or other, spread 
into the surrounding tissue. 

The writer remembers seeing the following case in Osier's 
clinic at the Orthopaedic Hospital. A young mother, about three 
months pregnant, came into a room where a child was sleeping 
in a cradle which was on fire. In rescuing the child she severely 
burned her wrist. She was very much impressed with the 
danger through which she had passed as well as with the burns, 
and in conversation she frequently remarked to her friends that 
she was afraid her own child would be in some way affected, and 
she seemed to worry about this considerably. She was delivered 
of her child at full term and there was noticed on the child's 
arm a nsevus situated on the flexor surface above the wrist cor- 
responding exactly both as to the position and shape of the 
scar on the mother's arm. How the maternal impression could 
produce, if it really did produce, this effect is not known, 
but many. cases similar to the above are recorded in medical 
literature. 

In the cavernous angioma you have channels lined with endo- 
thelial cells such as are seen in the membranous portion of the 
penis. They are found especially upon the free surface of the 
liver in old people, and give rise to no clinical symptoms during 
life. 

Lymphangiomata. 

Here, instead of having the blood capillaries involved, as in 
angiomata, we have the lymphatics. In case the lymphatics of the 
tongue are affected the condition is known as that of macroglossia ; 
if the cheek, macrocheilia. 

Epithelial Tumors. 

Exhibits. 

1. Hard cancer of the breast. 

2. Colloid cancer of the stomach. 

3. Paget' s disease of the nipple. 

4. Primary cancer of the oesophagus with metastasis to the liver. 

5. Primary cancer of the gall-bladder. 

6. Squamous epithelioma of the penis. 



86 GENERAL PATHOLOGY. 

The epithelioma is especially apt to occur in those situations 
where the skin and mucons membrane come in contact the one 
with the other, such as at the lips or anus. Epithelioma of the 
sophagus is four times more frequent in males than in females. 

Adenoma. 

The adenoma may be defined as a tumor constructed upon the 

type of. and growing in connection with, a secretino- gland, but 
differs from it in being impotent to produce the accretion peculiar 
to the gland it mimics. 

Carcinomata. 

Carcinomata are turm-rs that always grow from pre-existing 

o-land-tissue and mimic the parent oland. but thev differ from 
adenomata in the fact that the structural mimicry i- incompk 
the epithelial cells, instead of exhibiting the regular disposition so 
constant in th<.se tumors, are in the cancers collected in the acini 



Fie. 4£ 








3*5 



: 'y 0^ 



' S'-f 



M 



Development of a cancer of the breast. X 300. (Hajult 
Acini which may be regarded as normal are often lined with a donble row of polyhedral 

or ronnded epithelial cells. 



and duct- in irregular cli - - or till them - apletelyas I _ 
rise to the appearan s of colum: - pithelial o - 

when seen under the microscope (Sutton). The varieties of car- 



EPITIIELIAL TUMORS. 



87 



cinorua are squamous, cylindrical, and glandular. Figures 43, 44, 
and 45, from Hamilton's Pathology, show very well the normal 
acini of the breast, then the adenomatous stage, and finally the 
production of a cancer, thus giving the easiest explanation of the 
formation of a cancer. 

Paget's Disease. 

Paget's disease is considered by some authorities as simply an 
eczema of the breast with a retracted nipple ; by others as an 
early lesion of cancer. The experiments performed by Power, 



Fig. 44. 




Lobule of the gland in which, the acini are in the adenomatous stage. X 50. 

(Hamilton.) 

Some normal acini are seen, but most of the acini are distended with epithelial cells. The 
stroma is seen surrounding the acini and is not yet invaded by the cells. 

of injecting the fresh material of a Paget's breast into the previously 
irritated vagina of a white rat, would seem to show that the con- 
dition can be communicated from one animal to another, and that 
it is similar to the growth from the coccidia. 



Encephaloid Cancer. 

An encephaloid cancer is the synonym for a soft or medullary 
cancer ; the scirrhus cancer is equivalent to a hard cancer. 



55 



GENERAL PATHOLOGY. 



It was formerly thought that the cancerous cells were peculiar. 
These cannot be told from other epithelial cells which are to be 
found normallv iu the bodv. 



Fig. 45. 




The acini in the upper portion of the figure are still adenomatous, while those in the lower 

part have "become cancerous, x 350. (Hamilton.) 

The stroma having given way, the cells are now escaping into the surrounding tissue 

and forming nests. 



Cuirass Cancer. 

Cuirass cancer is an induration of the skin after the removal of 
the tumor growth, in which the resemblance to a shield is marked. 



Lymphatic CEdema. 

Lymphatic o?dema is a condition in which the circulation of a 
part or limb is so interfered with that the return of the blood by 
the veins is difficultly accomplished. 



The verdict of " not proven •" must be given in regard to whether 
or not cancer is due to one of the lower forms of life. 



PART II. 

POST-MORTEMS 



As the usual object of au autopsy is to find out the cause of 
death, either for legal or scientific purposes, all post-mortems 
should be conducted in as thorough and accurate a manner as 
possible. For this reason it is well to have a routine method 
of examining the body, which is only to be departed from in 
exceptional instances, and to dictate all notes while the au- 
topsy is in progress. Drawings, photographs, casts, cultures of 
micro-organisms and microscopic slides are valuable additions 
to a well-written account of an autopsy. One post-mortem 
thoroughly worked up is of more value than one hundred incom- 
plete ones. 

In writing the account of an autopsy describe what you see ; 
do not use names of diseased conditions. These should be put in 
under the head of pathological diagnosis. One should first of all 
learn the normal appearances of the organs in order that the ab- 
normal may not be mistaken for the normal. A lesion found in 
one portion of the body will often suggest a careful search for a 
lesion in another part of the body, even though far distant ; for 
example, a multiple melanotic sarcoma of the liver would cause 
you to examine the eye for the primary lesion. Do not jump at 
conclusions too quickly. Tentative diagnoses alone should be 
made until the post-mortem is completed. And even after a most 
careful post-mortem, it is at times impossible to tell from what the 
patient died. 

Get all the anatomical knowledge you can out of every autopsy 
you make. It is, therefore, usually advisable, especially in the 
case of females, to perform a preliminary laparotomy. Many 
surgical operations can be practised upon the body without dis- 
figurement, such as Alexander's operation, oophorectomy, removal 

7 



90 POST-MORTEMS. 

of the ear ossicles and vermiform appendix, stretching of the 
sciatic nerve, symphysiotomy, etc. 

Yon should be -ure that yon have a legal right to make the 
post-mortem before yon begin. The nearest relative, or the one 
who is going to pay the expenses of the funeral, should give the 
consent in writing. If there be the slightest suspicion of foul- 
play make the case a Coroner's one. The feelings of the friends 
should be respected in every possible manner, and one should re- 
member that scientific and pathological zeal is no excuse for doing 
anvthinu- that mav in any way shock the feelings of those who are 
brought in contact with the dead. One poorly conducted autopsy 
in your neighborhood may prevent you from obtaining a dozen 
others. The laity should be encouraged to ask for the making of 
autopsies, so that a natural desire may exist among the public ; 
in seeking to foster this spirit you can well see that incalculable 
damage may be done in a community by a single ill-conducted 
autopsy. Tact will get you many autopsies. Curiosity of relatives 
and friends can often be worked upon to get permission for an 
autopsy. Those holding insurance papers will often find a blank 
asking whether or not a post-mortem examination has been made. 
A much stronger case is certainly made out when a post-mortem 
examination has been conducted by the attending physician. 

Invite your friends to the autopsy. The recent graduate is one 
who is usually picked out to start the autopsy. Be prepared for 
all sorts of suggestions (many of them absurd) from those who are 
attending the autopsy, though two heads are often better than one. 
Per contra, if you are not making the autopsy yourself, do not be 
forward in making suggestions to the one who is making it : 
but always be ready to do anything that you are asked to do in 
connection with the autopsy. 

Any organ which you desire to save should be placed in a safe 
place, so that it will not be returned to the body and sewed up. It 
is not wise to take away more tissue from a post-mortem than you 
are thoroughly able to work up. Permission should be asked for 
any specimen which you may take away, but it i- not necessary 
to ask the nearest relative, as in getting permission for the 
autopsy, or to tell the actual amount of material you are going to 
remove. 

Label all your specimens at once with the name of the person 
from whom the specimen is removed, character of the specimen 
and relations in the body, date, and preservative fluid employed. 



INSTRUMENTS FOR AN AUTOPSY. 91 

Some Legal Considerations. 

If you discover suspicious lesions while making an autopsy 
always stop the post-mortem and report the case at once to the 
Coroner. 

In legal cases be sure to protect yourself in every possible way. 
The jars (which should never have been used) containing the 
specimens should be sealed in the presence of a witness. In im- 
portant cases here in Philadelphia, the Coroner has both of his 
physicians present at the autopsy, so that the testimony is stronger ; 
and in case of absence of one of the physicians the other can go 
on the witness stand, and the case not be postponed. 

In Germany the legal evidence of a post-mortem held by gas- 
light has been adjudged by the court, except under certain peculiar 
circumstances, to be void. 

You should familiarize yourself with the medical laws of the 
State in which you practise. In some States the law obliges the 
physician to state professional secrets after the death of the patient 
on the demand of the heirs-at-law. 

If you value your peace of mind do not put yourself forward 
as an expert witness in medico-legal matters. Knowledge which 
you already have should be freely given to the court in criminal 
cases, but the court cannot compel you to obtain expert knowledge 
without your consent. 

Instruments for an Autopsy. 

A post-mortem set with its box is more of a luxury than a 
necessity. With the exception of removing the brain and cord, 
an autopsy can usually be made with a penknife. A post-mortem 
can be made with the hand, through the rectum, without even the 
use of a knife. 

The following instruments are to be found in a post-mortem set : 
Those marked with a star are the most important ; those with a 
dagger can be dispensed with without any difficulty. 

* One large and one small section or cartilage knife. The knife 
should be strongly made ; there is no necessity for an expanded 
and flattened portion on top of the blade for the index finger to 
rest upon. Of all things, a sharp-pointed knife is to be abhorred. 
Post-mortem wounds usually occur from three sources : first, from 
sharp-pointed knives — the wound being an incised wound ; second, 



POST-MORTEMS. 

from scratching your hand on bone, as when the sternum is broken. 
or upon the first rib. The nature of this wound is more thu: : 
an inoculation, as is seen in vaccination ; third, from someone else 
cutting you while assisting in opening the head or elsewhere. 

* A scalpel such as is round in your diss _- ses. 

A brain knife, which should have a long thin blade. Wet befc re 
using. 

f A stotome. This instrument is expensr 

Tw pairs : sciss is, * one having a rounded end. 

Enterotome. one end being curved upon itself and not sharp. 
with a shorter blade abo 
A blow-pipe. 
S eral pDnbes. A piece of broom-grass makes a good probe. 

* A saw. Be sure to have the blade attached to the handle. 
They are often made in two pieces and are apt to be loosened. 

+ A H - saw. useful for sawing the angles in opening the 
skull. 

A tenaculum. 

A metal catheter. 

A mallet or steel hammer; the end should have a blunt h 
for the removal of the skull-cap, 

^:eel chisel with a guard about one-half inch from the bl: 
end, to prevent injury to the brain. It may have: -s-bar as 
on a corkscrew, and can then be used in a twisting manner to 
remove the skull-cap. 

f A straight steel chisel for reniov i:_^ inal cord. 

~ P;:.ir ■:■:' i : : :I Oviir-r'M'OrV-s. 

* Carpet needles of good size. 

liper compasses or pelvimeter. 
A steel spring measure. 

.dnated 
I iraduated glasses ; * one large and one small. 
A pair of - 
Litmus pap 
I. _ 1*8 s lution. 

* A good hand-gla— . 

+ A portable steel tripod rest for the head. 

The following instruments can be purchased for ah $5.00, 
and kept rolled up in a chamois skin ready for os 



INSTRUMENTS FOR AN AUTOPSY. 93 

A large section knife and a scalpel. 

Enterotome. 

Chisel. 

Saw. 

Large needle. 

Pair of scissors. 

A well-apportioned mortuary room, such as is seen at the 
University, should contain a table upon which are to be placed the 
instruments, scales, plates, etc. Plenty of running water, a 
spigot being arranged above the post-mortem table so as to allow 
the water to flow directly on the body. The table should be about 
seven feet long, two feet nine inches high, and drain toward the 
centre by means of a depression, which should be connected with 



Fig. 46. 




a drain and a ventilating shaft. For class purposes the table 
should revolve, and, by an ingenious arrangement of a fulcrum 
and lever attachment, the weight of the body can be determined. 
A skylight above and a billiard-table gaslight should be directly 
over the table. A block for the head, or the rest used by the 
undertaker, should be provided. A wooden board for the exami- 
nation of the organs should be provided for section work, as they 
slip when placed upon the slab. A sink for washing out the intes- 
tines, or if this is not at hand, a bucket and washbasin. Museum 
jars or preserving jars (as in Fig. 46) and bottles containing different 
percentages of alcohol and Midler's fluid should be on hand. 



94 POST-MORTEMS. 

It is the custom in this country and in England to give the 
weights of the organs in avoirdupois ounces, their dimensions in 
inches, and capacity in cubic inches, though the Continental method 
of using grammes, centimetres, and cubic centimetres is fast gain- 
ing ground. Troy weight is sometimes used, and may give rise to 
much confusion. The grain is the same in both. 

An ounce avoirdupois is equal to 437.5 grains, or 28.3 grammes. 

An ounce Troy (or apothecaries' weight) is equal to 480 grains, 
or 31.1 grammes. 

To convert grammes into avoirdupois divide by 28.3 ; into Troy, 
by 31.1. Conversely, to convert avoirdupois into grammes, mul- 
tiply by 28.3; into Troy, by 31.1. 

A kilogramme equals 1000 grammes. 

A gramme equals 1000 milligrammes. 

A litre equals 1000 cubic centimetres, or 61.027 cubic inches, 
which is equivalent to 2.113 American pints or 1.76 English pints. 

A metre equals 1000 millimetres, or 39.37 inches. 

The weights and sizes of the important organs and structures of 
the body are given in the following tables (from Ziegler) : 

I. Average height (European standard) : 

Adult male, 172 centimetres. 
Adult female, 160 centimetres. 
Newborn male, 47.4 centimetres. 
Newborn female, 46.75 centimetres. 
A child at two years is about one-half as large as it will ever be. 

II. Average weight (European standard) : 

Adult male, 65 kilogrammes. 
Adult female, 55 kilogrammes. 

Newborn child, 3250 grammes ; the male being usually 
slightly the heavier. 

The English and American insurance standard (from Finlayson's 

Clinical Manual) : 

A man of 5 feet should weigh 
A man of 5 feet 3 inches should weigh 
A man of 5 feet 6 inches should weigh 
A man of 5 feet 9 inches should weigh 
A man of 6 feet should weigh 

A stone is equal to 14 pounds. 



Stones. 


Pounds. 


8 to 9 


120 


9 to 10 


130 


10 to 11 


143 


11 to 12 


155 


12 to 14 


170 



INSTRUMENTS FOR AN AUTOPSY 



95 



According to Orth, the mean height of a full-term, sound child 
is between 50 and 51 centimetres, the male being slightly longer 
than the female. The weight of a full-term boy at birth is 3600 
grammes, of a girl 3250 grammes. For the last five lunar months 
of foetal life, if the height expressed in centimetres be divided by 
five, the approximate age of the child in lunar months will be 
obtained. For example, if the child measures 35 centimetres, 
divide this by 5, and we have 7 as the number of lunar months 
which the child has passed in utero. The foetal age of the child 
in the first 5 months represents about the square root of the height 
expressed in centimetres. For example, if the height is 16 centi- 
metres, the child is 4 lunar months old. 



III. The approximate weight of the internal organs -} 





Adult. 


Newborn. 




grammes. 


grammes. 


Brain 


1397 


385 


Heart 


304 


24 


Lungs . 


1172 


58 


Liver 


16] 2 


118 


Pancreas 


201 


11.1 


Right kidney 


141 


— 



Adult. 



Newborn. 



grammes. grammes. 

Left kidney . 150 — 

Both kidneys 299 23.6 

Testicles . 48 0.8 

Muscles . 29,880 625 

Skeleton . 11,560 445 



IV. The body weight by percentage 





Adult. 


Newborn. 




Adult. 


Newborn 




per cent. 


per cent. 




per cent. 


per cent. 


Heart . 


0.52 


0.89 


Liver . 


2.77 


4.39 


Lungs . 


2.01 


2.16 


Brain . 


2.37 


14.34 


Stomach and 






Thymus gland 


0.0086 


0.54 


alimentary 






Skeleton 


15.35 


16.7 


canal 


2.34 


2.53 


Muscles 


43.09 


23.4 


Pancreas 


0.346 


0.41 









V. The weights, according to Gray's Anatomy, American edition 
by Keen, expressed in avoirdupois ounces and in grains : 



The average normal weight of the 



Brain 



Male. 
49t ounces. 



Female. 
44 ounces. 



It is heavier than in any animal except the elephant, 8 to 10 
pounds ; and in the whale, 4 to 5 pounds. 



1 Tables are from Vierordt, quoted by Ziegler, 7th ed., vol. 1, p. 181, German edition. 



96 POST-MORTEMS. 

The spinal cord freed from membranes and nerves weighs 1J 
ounces, or, in proportion to the encephalon, 1 to 33. 

Male. Female. 

Heart . . 10 to 12 ounces. 8 to 10 ounces. 

To body weight, 1 to 169. To body weight, 1 to 149. 

Pathologically, the heart may weigh over 1000 grammes. 

Lungs, both weigh 42 ounces, the right being 2 ounces heavier 
than the left; proportion to body weight, in male as 1 to 37, in 
female 1 to 43. In pneumonia one lung may weigh 4 or 5 pounds, 
or in atelectasis the weight may be but several ounces. 

Males. Females. 

Kidneys . . . 4J to 6 ounces. 4 to 5J ounces. 

Supra-renal s, 60 to 120 grains. 

Liver, 50 to 60 ounces ; according to Leidy, 1 to g- less than in 
the female. At birth it is nearly twice as large in proportion to 
the body-weight as in the adult. Spleen (very variable), 7 ounces. 

The testicle, 6 to 8 drachms, the left being slightly the heavier. 

Thyroid gland, 1 to 2 ounces. 

Thymus at birth, J ounce. 

Pancreas (very variable) — several ounces (2 to 6). 

Prostate, 6 ounces. 

Uterus, 1 to 1J ounces. 

Ovaries, 1 to 2 ounces. 

Stomach, 4 J ounces. 

"VI. Dimensions 1 of the important organs : 

Brain. 

Volume, 1330 cubic centimetres. 
Specific gravity, 1035 to 1040. 
Length : man, 160 to 170 millimetres. 

" woman, 150 to 160 millimetres. 
Greatest transverse diameter, 140 millimetres. 

" vertical diameter, 125 millimetres. 

Heart. 

Thickness of the right ventricle, 2 to 3 millimetres ; pathologi- 
cally being at times 7 to 10 millimetres. Left ventricle, 7 to 10 
millimetres ; pathologically, 20 to 25 millimetres. 

1 From Ortb. 



INSTRUMENTS FOR AN AUTOPSY. 97 

Measurements of the normal heart. 1 

Diameter of orifice, aortic, 0.9 to 1 inch. 
Mitral, 1.2 to 1.4 inch (two fingers). 
Pulmonary, 1.1 to 1.2 inch. 
Tricuspid, 1.5 to 1.8 inch (three fingers). 

Spleen. 

Volume, 221.5 cubic centimetres. 
Length, 12 to 14 centimetres. 
Breadth, 8 to 9 centimetres. 
Thickness, 3 to 4 centimetres. 

Kidney. 

Length, 11 to 12 centimetres. 
Breadth, 5 to 6 centimetres. 
Thickness, 3 to 4 centimetres. 
Or in the proportion of 1 : J- : J. 

Liver. 

Volume, 1574 cubic centimetres. 

Transverse diameter, 25 to 30 centimetres. 

Right lobe, 18 to 20 centimetres. 

Left lobe, 8 to 10 centimetres. 

Longitudinal diameter : right, 20 to 22 centimetres. 

" " left, 15 to 16 centimetres. 

Greatest thickness, 6 to 9 centimetres. 
A fatty liver may be so light as to float on water. 

The adult alimentary tract is about thirty feet in length, the 
small intestine being about twenty feet long, and the large intestine 
about five feet in length. Much variation from these figures occurs ; 
the writer has seen the sigmoid flexure become dilated and push 
up the diaphragm, or form a part of a complete inguinal hernia of 
the right side. The large intestine will hold about three litres, 
and the small intestine an equal amount ; the oesophagus and 
stomach about two litres. 

The method of telling the right lung from the left is by the 

1 From Hamilton. 



98 POST-MORTEMS. 

right having three lobes. This is very constant, the writer only 

recalling one case out of many hundreds where the opposite con- 
dition prevailed. As the student is apt to get contused upon 
which side the three lobes are. it can be remembered in connection 
with the tricuspid and mitral valves — tricuspid (three valves | right 
side, mitral (two valves) left side ; this corresponds to the number 
of the lobes in the lung upon the same side. 

The apex of the lung, with its tapering cone, can usually readily 
be told from the concave and broad base. After determining this. 
remember that on the right side, from above downward, we have 
bronchus, pulmonary artery, and pulmonary veins ; while on the 
left side it is pulmonary artery, bronchos, and pulmonary vein. 

The method of telling the right kidney from the left depends 
upon the following anatomical data : 

Right kidney. Left kidney. 

Impressio renalis from liver. Xo impressio renalis from spleen. 

Shorter and broader. Longer and narrower. 

About 5 to 7 grammes lighter. About 5 to 7 grammes heavier. 

The spermatic or ovarian vein The spermatic or ovarian vein 

empties into the inferior vena empties into the renal. 

cava. 

The posterior surface of both kidneys is flatter than the anterior, 
the external border being convex and the internal border concave, 
and the top more expanded than the lower portion. At the 
hilum, the arrangement of the vessels of the kidney is — front al 
(anteriorly), downward (posteriorly) — vein, artery, ureter - v a d . 
The kidney is placed upon the table in front of the examiner on 
its posterior surface, with its lower extremity toward the observer, 
and the ureter pointing downward. The ureter is then behind 
and below the other vessels, the hilum being directed to the side 
of the operator to which the kidney belongs, i. <-:.. if toward the 
left hand of the observer, it is the left kidney, and if toward the 
ght hand it is the right kidney. 

Other methods of telling the right-sided organs from the left 
will at once suggest themselves, as. placing the right-sided organs 
on the right side of the body, and the left-sided organs on the left 
side. This is subject to confusion from change. The writer has 
found it very convenient to nick the left-sided organs with one 
nick or cut. as the left-sided organs are first removed from the 
body, and the right-sided organs with two nicks or cuts, and they 
can thus be readily distinguished the one from the other. 



spinal column. 99 

Order of Examination in an Autopsy, and what should 

be looked for. 

(Based largely on Virchow's and Orth's works on the subject.) 

A. External Examination. 

In medico-legal cases this is often of the most importance, while 
in medicine the internal examination of the body is more in- 
structive. 

1. External inspection of the body in general. 

a. General bodily relations. Age, sex, height; various 

dimensions of the body, such as head, chest, waist, 
arms, limbs, etc.; nutrition, weight. 

b. The signs of death and decomposition. Rigor mortis, 

post-mortem lividity. 

2. Data of interest to Coroner, such as position of the body, 
wounds, fluids scattered around, etc. 

3. External inspection of each individual part of the body, as 
hair, eyes, nose, ears, extremities, penis, etc., and for jaundice, dis- 
eased joints, contractures, oedema, hernia, hydrocele, etc. 

4. External inspection of the newborn. Signs of inflammation 
of the cord, ophthalmia neonatorum, hsematoma, dislocations and 
fractures, the state of the fontanelles, mastitis, hernia, especially 
umbilical, spina bifida, pemphigus, thrush, icterus, cyanosis and 
malformation, such as hare-lip, cleft palate, tongue-tie, polydac- 
tylism, monstrosities, abnormal openings, imperforate anus and 
rectum, etc. 

5. Diseases of the skin and of the underlying tissues. 

a. General alterations. 

1. Epidermis. 

2. Cutis. 

b. The individual ailments. 

B. Internal Examination. 
I. Spinal Column. 

1. Soft parts and bones. 

2. Spinal cord and its coverings. 

a. General relations. 



100 POST-MORTEMS. 

b. The individual diseases of the — 

1. Dora mater. 

2. Pia mater. 

3. Spinal cord. 

II. Head. 

Scalp, thickness, vascularity, etc. 

1. Periosteum. 

2. Bones (from without). 

a. General relations. 

b. Individual diseases. 

3. Bones (from within). 

4. Dura mater (convexity from without). 

a. Dura itself. 

b. Longitudinal sinus. 

5. Dura mater (convexity from within). 

a. General relations. 

b. Diseases common to it. 

6. Pia mater (convexity). 

a. General relations. 

b. Diseases common to it. 

7. Removal of the brain. 

8. Pia mater of the base. 

a. Its large vessels. 

b. The pia mater itself. 

9. Brain (from without). 

10. Internal examination of the brain and its ventricles. 

1. Abnormal contents and enlargement of the ventricles. 

2. Ependyma. 

3. Choroid plexus. 

a. Sections of the cerebrum. 

1. Section of the hemispheres. 

2. Sections of the greater ganglia. 

6. Fourth ventricle. 

c. Cerebellum. 

d. Pons Varolii and medulla oblongata. 

e. Different methods of dissecting the brain. 

f. Microscopical examinations of the brain. 

g. Diseases of the brain. 

11. Dura mater and bones of the base of the cranium. 



THORAX AND ABDOMEN. 101 



12. Face. 

a. Parotid gland. 

b. Bones of the face. 

13. Nostrils. 

14. Eyes. 

a. Retina. 

b. Choroid. 

c. Eyeball. 

15. Organs of hearing. 



III. Thorax and Abdomen. 

1. External soft parts. 

a. Pannicnlns. 

b. Muscles. 

1. General relations. 

2. Individual diseases. 

2. Inspection of the abdominal cavity. 

a. Relation of organs. 

b. Color (amount of blood). 

c. Abnormal contents. 

d. Peritoneum. 



A. Section of thorax. 

1. External inspection. 

a. General relations. 

b. The various bones. 

2. Opening of thorax. 

3. Bones of sternum from within. 

a. Sternum. 

b. Ribs. 

c. Sterno-clavicular articulation and clavicle. 

4. Inspection of the thoracic cavity. 

a. Appearance of exposed lung tissue. 

b. Pleural cavities. 

5. Mediastinum (middle) and contents. 

a. Tissues. 

6. Mediastinal lymphatic glands. 

c. Thymus gland. 



102 POST-MORTEMS. 

6. Pericardium. 

a. Contents. 

b. Diseases (pathological changes). 

c. Sub-pericardial adipose tissue. 

7. Heart. 

a. External inspection. 

b. Opening in situ. 

c. Blood. 

d. Removal of heart and continuation of dissection. 

e. Internal exploration of the heart. 

1. General relations. 

2. The various diseases. 

8. Lungs. 

a. Pleura. 

b. Opening in situ. 

c. Internal inspection of the lung. 

1. General relations. 

2. The various diseases. 

a. Of the parenchyma and the smaller bronchi. 

b. Of the larger bronchi. 

c. Of the vessels of the lung. 

d. Of the bronchial lymphatic glands. 

9. Costal pleura and posterior sections of ribs. 

10. Organs of the neck. 

a. Method of dissection. 

b. Observation of the various parts. 

1. Large vessels and nerves. 

2. Mouth and pharynx. 

3. (Esophagus. 

a. General relations. 

b. Various diseased conditions. 

4. Larynx and trachea. 

a. General relations. 

b. Various diseases. 

c. Examination of sputum. 

5. Submaxillary glands. 

6. Thyroid glands. 

7. Lymphatic glands of the neck. 

11. Deep muscles of the neck and cervical vertebra. 

12. The lung test of newborn infants. 



THORAX AND ABDOMEN. 103 

b. Section of abdominal cavity. 

1. Anterior layer of peritoneum. 

2. Mesenteries. 

3. Spleen. 

a. External observation. 

1. General relations. 

2. Capsule of spleen. 
6. Internal observation. 

1. General relations. 

2. Various diseases. 

4. Kidneys and adrenals. 

a. Adrenals. 

b. Kidneys. 

1. Capsule of kidney. 

2. Examination of the parenchyma. 

a. General relations. 

b. Peculiar changes. 

3. Internal examination of the parenchyma. 

a. General relations. 

b. Various pathological changes. 

4. Tufts, pyramids, calyx, ureters. 

5. Urinary organs. 

a. Capacity of bladder and contents. 

b. General dissection method. 

c. Bladder and urethra. 

1. Bladder. 

a. General relations. 
6. Various diseases. 

2. Urethra. 

d. Penis. 

e. Prostate gland. 

/. Seminal duct and spermatic cord. 

g. Testicles, rete testis and spermatic cord. 

1. Vas deferens and tunica vaginalis. 

2. External examination of testicles and rete testis. 

3. Internal examination of testicles and rete testis. 
h. Vulva. 

1. General relations. 

2. The various diseases. 
Jc. Uterus. 



104 POST-MORTEMS. 

1. External examination. 

2. Internal examination. 

. relati - 
Various discs ses 
L Broad ligaments and parametrium. 
Fu] es Fallopian). 
Ovaries. 

1. External examination. 

2. Internal examination. 

o. Douglas 5 pc l or retro-uterine peritoneum. 
1. Extra-uterine pregnancies. 
Rectum. 
1. General relations. 
_ . Various iseases 
Duodenuni and stomach. 

a. External inspection. 

1. General relati - 

_ Changes of the serosa. 

b. Internal examination. 

1. C nts. 

_ Mi is membrane of duodenum. 

3. Mucous membraiir : stomach. 

. General relati' as 
b . Various diseases. 
:. Exanrii:::: >n : the stomach in suspected poison cases. 
1. Examination meth<xl. 

hanges ;»roduced by poisons. 
Thi no-hepatic ligament. 

a. Ductus choledochus. 

b. Purtal vein. 
.1-bladder and liv 

a. Gall-1 ladder. 

1. External examination, 
a. « 1 relati 

S :-sa. 
_ Internal examination. 

a. Content* 

b. P«:»sition. 

b. Portal <'peniug and lymphatic gland-. 
Li 

1. External observation. 



EXTKEMITIES. 105 

a. Capsule of liver. 

b. General relation. 
2. Internal examination. 

a. General relation. 

1. The parenchyma as a whole. 

2. The various lobules. 
6. The various diseases. 

9. Pancreas. 

a. Gland parenchyma. 

b. Pancreatic ducts. 

10. Coeliac ganglion. 

11. Mesenteries. 

a. Connective tissue of. 

b. Mesenteric lymphatics. 

c. Large vessels of the mesentery. 

12. Intestines. 

a. External observation. 

1. General relations. 

2. Serosa. 

b. Opening of the intestines. 

c. Contents of the intestines in an examination of same. 

d. Position and volvulus of intestines. 

1. General relations. 

2. Various diseases. 

13. Great vessels and the accompanying lymphatic glands. 

a. Veins. 

6. Arteries , especially aorta. 

1. General relations. 

2. Various diseases. 

c. Retro-peritoneal lymphatic glands. 

d. Thoracic duct. 

14. Internal muscles of the body. 

a. Diaphragm. 

b. Ilio-psoas. 

15. Cervical vertebrae (from within). 

a. General relations. 

b. Various diseases. 



IV. Extremities. 



1. Lymph glands. 

2. Lymph vessels. 



POST-MORTEMS. 

3. Vessels. 

4. Nerves. 

5. Moscles. 

a. General relations. 

b. Various diseases. 

6. Joints. 

a. External examination. 
6. Internal examination. 

1. Contents. 

2. Internal ligaments. 

3. Synovial membranes. 

4. Joint surfaces. 

o. The various diseases of joints as a whole. 

7. Bones. 

1. General examination of bones as a whole. 

2. Examination u£ bones individually and in part-. 

a. Periosteum. 

1. General relations, 

2. Various diseases. 

b. Tela ossea. 

1. General relation-. 

2. Various diseases. 

c. Marrow. 

1. General relations. 

2. Various diseases. 

3. Diseases of the bone- as a whole. 



Heading for a Post-mortem Book. 

A post-mortem book should be prepared tor each hospital, and 
the notes should be made while the autopsy is in progress. The 
following printed words may lie placed at the tup. 

Number of autopsy, Xanie, 

Ag Sex, Color, 

Address, 

Occupation, Married or Single, 

Nationality, Place where held. 

Commenced auto] >ur) (day (month) 

Ended (hour) (minufc 

If hospital : Ward, No. of bed. 



EXAMINATION OF THE BODY. 107 

First visit in last sickness, ,189 Died, 

Autopsy commenced hours after death. 

Weather : cold, mild, or hot. 

Mode of death : sudden or slow. 

Clinical diagnosis, 

Attending physician, 

Physicians present at autopsy, 

Permission given by 

Performed by 

Pathological diagnoses, 

Specimens taken, 

Character of preservative fluid, 



Order for the Examination of the Various Parts 

of the Body. 

1. Examination of the exterior of the body. 

2. Examination 1 of the abdominal cavity. 

3. Examination 1 of the thoracic cavities. 

4. Pericardium. 

5. Arch of the aorta. 

6. Heart. 2 

7. Nares, larynx, and trachea. 

8. Lungs. Left. Right. 

9. Spleen. 

10. Intestines. 

11. Left adrenal and semilunar ganglion. 

12. Left kidney. 

13. Right adrenal and semilunar ganglion. 

14. Right kidney. 

15. Ureters. 

16. Bladder. 

17. In the male : Prostate, spermatic cord, urethra, testicles, etc 
In the female : Uterus, tubes, ovaries, broad ligament, etc. 

18. Duodenum. 

19. Stomach and oesophagus. 

1 At this time none of the organs are to be removed from the body or their relations mark- 
edly disturbed. 

2 After tbe heart is opened it is wise to have someone start on the head. 



108 POST-MORTEMS. 

20. Liver. 

21. Pancreas. 

22. Retro-peritoneal glands, thoracic ducts, aorta, vena cava, etc. 

23. Head. a. Membranes, b. Brain, c. Eye. d. Ear. 

24. Spinal cord. 

25. Other organs. 

26. Remarks. 

27. Microscopic examination. 



Preparation for an Autopsy. 

Place. The manner in which the autopsy is made will depend, 
to a certain degree, upon the place where it is held, as when 

1. At a private house or at the undertaker's. 

2. At the hospital or morgue. 

1. If an adult, the coffin-lid, or, still better, the coffin turned 
upside down, a door taken from its hinges and placed on two 
chairs, a kitchen table ; or, if a child, the marble slab from a 
bureau will afford a resting-place for the body. Do not have 
the body too low, as the stooping position, if too long continued, 
causes intense pain in the back. 

Bring with you a post-mortem set, dissecting apron, surgeon's 
coat, two sponges, a graduate holding at least one-half pint, needle 
and carpet thread to sew up body, piece of rubber like that used 
in confinement cases, piece of oil-silk or have a special bag so 
prepared that fluid will not escape from it, note-book and pencil, 
bromine, celloidin in solution, small roll of cotton, four small 
two-ounce bottles with broad mouths for microscopic specimens — 
have one filled with 70 per cent, alcohol, one with 95 per cent., 
another with Miiller's fluid, and the fourth with a saturated solu- 
tion of bichloride of mercury. Ask for two buckets of water, 
half filled, an empty basin, and a half-dozen towels. 

If possible, the post-mortem should be made before the body is 
dressed for the funeral. Get the relatives, friends, and, if possible, 
the undertaker out of the room before commencing the autopsy. 
A surgeon's coat and an apron, with the sleeves well rolled up. 
and you are ready for work. The undertaker has usually spread 
a piece of mackintosh on the floor ; if not, an old piece of carpet 
should be requested for this purpose. The autopsy is then made 
in the order described on pages 107 and 108, and in the manner 
directed in the following pages. 



EXAMINATION OF THE EXTERIOR OF THE BODY. 109 

In private cases your skill as a pathologist will be frequently 
judged of by the neatness with which you sew up the body and 
the care with which you clean up after the autopsy is completed. 
Be sure to leave no blood-stains behind. 

2. In the hospital or morgue everything is arranged much more 
completely, and the autopsy can, therefore, be conducted more 
easily, more comfortably, and better. 

I. Examination of the Exterior of the Body. 

It would be well if this was done more frequently and thor- 
oughly during life, as valuable information can frequently be dis- 
covered in this manner. Get all the information you can from 
the physician, friends, police, etc. People like to talk, and it is 
surprising how much one can learn in this manner. Notice espe- 
cially the state of nutrition of body ; weight ; circumference of the 
shoulders and head ; height (in a child take the ordinary foetal 
measurements and examine the fontanelles, sutures, etc.) ; appear- 
ance of the skin, such as eruptions, scars, wounds, bruises, etc. ; 
deformities ; other peculiarities, such as jaundice, oedema, hernia, 
hydrocele, etc. ; rigor mortis ; decomposition ; post-mortem lividity. 
Discharges from the various orifices, such as ear, nose, mouth, 
vagina, urethra, etc., should be carefully observed and note made 
of any foreign bodies inside of them. 

Look for bedsores, external parasites, such as pediculi, 1 color of 
hair, eyes (remember that jaundice can best be told in the con- 
junctiva, and that, as the eyes are closed by the undertaker, they 
should be carefully shut after the examination has been completed), 
scars on the genitalia, mucous membrane of the mouth, teeth, 
breast, distention of the linese albicantes, thickening of the perios- 
teum of the leg, amount of fat, petechia?, muscular development, 
wasting of muscles, skin of the throat. 

The external examination is of the utmost importance in all 
medico-legal cases, and great care should be exercised in a thor- 
ough description of the surroundings, such as in a case of cut 
throat, whether the razor was held in the hand, or found upon the 
right side of the body, or whether the person had committed 
suicide while looking into a glass, etc. 

The operator stands upon the right side of the body. A block 

1 By means of a towel soaked in chloroform and placed upon the head, pediculi can 
be quickly and safely disposed of. 



110 



POST-MORTEMS. 



can be placed under the shoulders to elevate them if it be desired 
to do so. Holding the knife as in Fig. 47 or Fig. 48, he makes 



Fig. 47. 




Method of holding the large section knife for the primary incision. 



Fig. 48. 




Another method of holding the section knife. 



EXAMINATION OF THE EXTERIOR OF THE BODY. Ill 



Fro. 49. 



a clean cut from the inter-clavicular notch to the symphysis pubis, 
going to the left of the umbilicus, care being taken that the knife 
does not penetrate into the abdominal cavity. (Fig. 49.) The 
muscles are then dissected away from 
the sternum and ribs, and an opening 
is made through the peritoneum below 
the xiphoid cartilage, and the index 
finger and the middle finger are intro- 
duced, assuming an inverted V. The 
skin and muscles are then raised, and, 
the knife being introduced into the 
opening, the left hand is slid along as 
the knife cuts its way through the 
tissue, the cutting being done from 
within outward. In order to have 
still more room various means have 
been suggested, the two which are most 
applicable being the transverse incision 
on each side, about three inches above 
the umbilicus ; there will then be four 
flaps instead of two. Another method, 
which is easily accomplished and gives 
considerable room, is to cut the recti 
muscles near and in the direction of 
Poupart's ligament. It will not be 
found necessary to make both the trans- 
verse incisions and those of the recti. 

The hands should be washed from 
time to time, as the feeling imparted 
to the skin by means of dried blood is 
disagreeable. 

If you are so unfortunate as to cut 
yourself, wash the wound with running 
water four or five minutes, and then dress antiseptically. Do not, 
out of bravado, go on with the post-mortem if there be anyone else 
present who can complete it. The action of the direct rays of the 
sun upon wounds produced by certain micro-organisms is worthy 
of note and affords an opportunity for further investigation. If 
the case is one where micro-organismal infection be not feared, the 
post-mortem may be continued, a small piece of cotton being 
placed over the wound and attached to the skin by means of cel- 




The primary incision, A B, going 
to the left of the umbilicus at c d ; 
the secondary transverse incision, 
e f, making four flaps ; or the sec- 
ondary incision, cutting the recti, 
g h and i j, from beneath, and not 
the skin . 



112 POST-MORTEMS. 

loidin or flexible collodion. Post-mortem gloves, with long sleeves, 
are to be had in the stores. If you are attending a post-mortem 
where the operator is using these gloves be sure that he does not 
injure you, as the grasp of the knife is by no means so firm as 
when held in the naked hand. 

The rectus muscle is then examined for color, consistency, 
hyaline patches, encapsulation of trichinae spirales, etc. 

The muscles being thoroughly removed from the thorax by 
grasping the skin with the left hand and cutting, with the knife in 
the right hand, with a long, sweeping movement, the clavicle is 
grasped and moved in order to discover the situation of the articu- 
lation with the sternum ; the ligaments are then cut upon each side. 
The ribs are incised from within outward by means of the carti- 
lage knife or costotome, care being taken to cut the cartilage rather 
than the bone, the point of union being quite marked. The first 
rib is the only one that will give any trouble, and this, being com- 
pletely united to the sternum by means of ossification, should be 
cut through by the costotome or saw. The sternum is then raised 
and the diaphragm and other adhesions cut as closely as possible to 
the bone. In order to prevent scratching the hands the flaps are 
laid over the cut ends of the ribs. 

II. Examination of the Abdominal Cavity. 

In this examination none of the organs are to be removed from 
the body or in any way disturbed, so that their normal relations 
may, too, be again studied. Care should be exercised in examin- 
ing the color of the organs, such as the liver, before they may 
have become oxidized. This is especially striking upon section 
of organs such as the spleen or lungs. The relative position of 
all the organs should be carefully observed, such as the situation 
of the liver, stomach, and other viscera to the costal and xiphoid 
cartilages. Perforation, volvulus, intussusception, concealed her- 
nia, tumors, aneurism, contents of the bowels, whether fecal or air, 
points of adhesion, any signs of inflammation ; the extent of the 
diaphragm ; fluid, if any ; situation and condition of the vermiform 
appendix ; gall-stones ; estimated amount of urine in the bladder ; 
pregnancy, pus tubes, etc., if a woman. 

III. External Examination of the Thoracic Cavity. 

For the sake of uniformity, it is wise to examine the left-sided 
double parts or organs first. Notice here the amount of fluid — see 



HEART. 113 

if it be blood — position, distention, color, and general appearance 
of the lungs. Break up any adhesions which may be present, and 
introduce the hand posteriorly to the lungs and gently feel for 
pulmonary lesions, etc. Any fluid found should be carefully 
measured. Determine whether it is inflammatory or not. 

See the condition of the mediastinum, thymus gland, peri- bron- 
chial glands, which are often pigmented, and mistaken by the student 
for melanotic sarcoma. The thyroid gland can now be examined, 
or, if desired, the tongue, epiglottis, oesophagus, trachea, thyroid 
gland, etc., can be removed later on in a single piece. Notice the 
position of the pericardium ; see if it is distended with fluid, etc. 
Search for an aneurism. 

IV. Pericardium. 

The pericardium is elevated by means of the fingers or a tenacu- 
lum, and a small incision is made at its highest point, care being 
taken not to allow the escape of any fluid. Measure the amount 
of fluid. This can be readily withdrawn by means of a pipette, a 
syringe, or a small graduated glass. Examine situation of the 
heart, looking especially at the distention of the cavities with 
blood. See if there be pericarditis, tubercles, etc. The normal 
amount of pericardial fluid is about fifty cubic centimetres. Blood 
from a ruptured aneurism may fill the pericardial sac. 

V. Arch of the Aorta. 

This should always be carefully examined, as when an aneurism 
is present it is usually advisable to' remove the aorta attached to 
the heart. 

VI. Heart. 

Method of Opening Heart (after Virchow). 

With a knife make an incision in the right auricle, midway 
between the superior and inferior venae cava?, in the direction of 
the right ventricular ridge. Continue this incision in the same 
direction until the right auriculo-ventricular septum is reached. 
Examine the auricle for clots and determine the calibre of the 
right auriculo-ventricular opening, guarded by the tricuspid 
valves. In case this opening is occupied by a clot, the clot should 
be removed. The size of the opening is usually determined by 



114 



POST-MORTEMS. 



the number of fingers which can pass through the opening, though 
the graduated cones (see Fig. 50), or different sized balls placed 
on rods, should be employed. Xext make an opening in the right 
ventricle just below the auriculo- ventricular septum and the open- 
ing made in the auricle. Continue this incision down the right 
ventricular ridge until the ventricular septum is reached, which is 
a little to the right of the apex. The character of the clots in the 
ventricle is next determined. 

Fig. 50. 




Graduated cones used for measuring orifices. (Ha^hltox.) 



On the left side make an incision in the left auricle, in or 
slightly below the lowermost pulmonary vein. Continue the in- 
cision in the direction of the left ventricular ridge, stopping at the 
auriculo-ventricular septum. Examine the auricle for clots and 
determine the calibre of the left auriculo-ventricular opening, 
guarded by the mitral valve. An incision is next made in the left 
ventricle, along the entire length of the left ventricular ridge. It 
will be remembered that the left ventricle normally forms the apex 
of the heart ; therefore the incision will be carried through the 
apex before the ventricular septum will be reached. Examine the 
ventricle for clots. All of the above incisions are made while the 
heart is in situ in the body, and they may, therefore, be called the 
primary incisions of the heart. 



OPENING THE HEART. 115 

The heart is next to be removed from the body. For this pur- 
pose introduce the index finger of the left hand into the left ven- 
tricle and the thumb of the same hand into the right ventricle. 
Grasp the ventricular septum near the apex and elevate the heart, 
making slight traction on the bloodvessels. With a knife in the 
right hand cut everything which normally holds the heart to the 
body, viz., the inferior vena? cavse, the superior venae cavse, the 
pulmonary artery and aorta (near their exit from the cavity of 
the pericardium, first, however, having determined that there is no 
aneurism), and, lastly, the pulmonary veins. The competency of 
the pulmonary aud aortic valves is next tested by means of the 
introduction of water into the pulmonary artery and the aorta, the 
heart being evenly suspended by means of the great vessels. See 
that the coronary arteries are intact, or otherwise the water may 
run out through them, and the aortic valves will be stated to be 
incompetent. 

Lay the heart upon a board or hold it, with its posterior surface 
down, upon the left hand. Introduce a pair of probe-pointed 
scissors or a cardiotonic in the centre of the right ventricular in- 
cision, and cut toward the centre of the pulmonary artery. There 
are two anterior semilunar valves, and their junction can usually 
be seen from the outside; if not, their junction can readily be 
determined by looking into the pulmonary artery or by the intro- 
duction of the index finger. When practicable it is best to cut 
through their attachments. Continue the incision through the cut 
end of the pulmonary artery. Examine the. pulmonary valves, 
endocardium, muscle, chordae tendineae, etc. Dissect away the con- 
nective tissue which holds the pulmonary artery and aorta together. 
In the left ventricle cut the anterior ventricular wall as near the 
ventricular septum as possible until a point is reached where the 
left auricular appendage overlaps on to the left ventricle. The 
scissors are then introduced into the aorta (either from the aorta 
or ventricle) and the incision is made between two leaflets. Bear 
in mind that there is but one anterior leaflet, and the incision will, 
therefore, have to be made toward one side or the other. Examine 
valve, muscle, intima of aorta, etc. Next dissect out the coronary 
arteries. Lastly, upon both sides continue the auricular incisions 
into the ventricular, and thus complete the secondary incisions 
made outside of the body. It will be found that the mitral and 
tricuspid valves are not injured, and the entire heart can be folded 
together so as to again show its normal contour. 



116 



POST-MORTEMS. 



The incisions used in opening the heart are shown by using the 
letters seen in Figs. 51, 52, and 53. 

Primary Incisions. 

Make the incision A B in the right auricle, midway between the 
superior and inferior venae cava?, in the direction of the right ven- 
tricular ridge, stopping at the auriculo-ventricular septum.- Start- 
ing in the ventricle, near the auriculo-ventricular septum, make 
the incision C E down the right ventricular ridge to the ventricular 



Fig. 51. 



Fig. 52. 



Fig. 53. 




Fig. 51. — Lines showing the incisions which are to be made in the heart while it is in the 
body. These may be called the primary incisions, A B, C E. I H, and G F. 

Fig. 52. — Lines showing the incisions which are to be made in the heart outside of the 
body. These may be' called the secondary incisions, and can be divided into two sets — first, 
those for examining the ventricles and the arteries leading therefrom, DL and F J, and J K. 
and the second division, those joining the primary auricular and ventricular incisions, B C 
and H G. 

Fig. 53.— Lines showing combined primary and secondary incisions of the heart. 

septum. On the left side make the incision I H in the left auricle 
near or below the lowermost pulmonary vein, in the direction of 
the left ventricular ridge, stopping at the auriculo-ventricular sep- 
tum. Below the auriculo-ventricular septum make the incision, 
G F, into the ventricle, along the ventricular ridge to the apex. 



Secondary Incisions. 

Midway in the incision in the right ventricle make a cut, D L, 
in the direction of the centre of the pulmonary artery ; continue 
the incision to the bifurcation. In the left ventricle, at the apex, 



NARES, LARYNX, AND TRACHEA. 117 

make the incision F J until the point is reached where the left 
dog's ear (auricular appendix) overlies upon the left ventricle ; 
then, by introducing the instrument into the aorta, the aortic 
valves are seen, and the incision J K is made. On the right side 
make the incision B C by joining the auricular incision, A B, and 
the ventricular incision, C E. On the right side make incision 
H G by continuing the auricular incision, A B, to the ventricular 
incision, G F. 

The situation of the mitral and pulmonary valves can readily 
be remembered by the use of the mnemonic, " itfartin .Luther, The 
Reformer " — M itral on the .Left side ; Tricuspid on ifaght side. 
That there is but one Posterior cusp to the Pulmonary and one 
interior cusp to the ^Lorta will readily distinguish this often- 
forgotten question. 

VII. Nares, Larynx, and Trachea. 

It is frequently advisable to remove the tongue, oesophagus, 
trachea, epiglottis, etc., together. For this purpose, in those cases 
where disfiguration of the body is a matter of no importance, the 
primary incision over the thorax can be extended up to the sym- 
physis mentis and the part dissected out. There is no necessity 
for this, however, as, by careful manipulation, the hand can tear 
the skin away from its attachments by working from beneath, and, 
the entire part thus loosened, a knife can be introduced into about 
the centre of the tongue (through the genio-glossus muscle), pos- 
terior to the frenum of the tongue, thus leaving the tip in situ in 
case an examination of the mouth be made. 

By means of a circular incision, keeping as close as possible to 
the bony walls of the jaw, carotids and bodies of the vertebras, 
pharynx, and larynx, the entire parts may thus be separated, 
drawn forward, and removed. In the case of a child the entire 
body can then be eviscerated at once in the following manner : 
Grasp the trachea and oesophagus and elevate, cutting posteriorly 
as close as possible to the vertebral column until the diaphragm is 
reached. This is then cut laterally and posteriorly, the adhesions 
being again removed with the knife. The rectum is tied with two 
strings, and cut between the ligatures. Cut loose the crura, and 
the diaphragm is free. Anything which holds the abdominal 
organs in place is cut, and the body of the babe is completely evis- 
cerated. In the case of a female you can take the organs of genera- 
tion (also the bladder) along with the other organs by removing 



118 POST-MORTEMS. 

them in the same manner as in the adult. The advantage of this 
method is that the organs can be examined most conveniently 
both anteriorly and posteriorly, and, as all the organs are attached, 
the same relations are preserved as if they were left in the body. 
A child disembowelled in this manner can be kept for a long while, 
especially if the abdominal cavity be packed with a mixture of 
equal parts of bran and salt. A little white arsenic can be added 
with good effect to this mixture. The body can then be surrounded 
with cotton, and a circular bandage applied to the chest and thorax. 
You can sometimes advise the employment of this method of 
preserving the body as a means of gaining permission from a 
parent to hold the autopsy. 

The oesophagus and the trachea are preferably opened up pos- 
teriorly. 

Carefully examine the vocal cords ; see if there are any tumors, 
syphilitic or tubercular ulcerations, inflammation, malformations, 
foreign bodies, diphtheritic membrane, etc. 

VIII. Lungs. 

The serous surface is practically not visible unless inflammation 
has occurred. In order to remove the lungs, they having been 
thoroughly freed from the pleural adhesions, the upper lobe is 
grasped and carried away from the median line of the body so 
as to expose the vessels entering at the hilum ; the vessels and 
bronchi are cut through, cutting from above downward and back- 
ward. The left lung should be removed first. 

It sometimes happens where the adhesions are very strong that 
it is necessary to dissect away the ribs along with the lung. The 
incision in these cases into the lung can frequently be made with 
advantage by leaving the lung in situ. 

Examine outer surface for fibrinous exudation, color, minute 
hemorrhages, fibrinous adhesions, nodules, excessive pigmentation, 
spots of emphysema, miliary tubercles, consolidated patches, cica- 
trices, hemorrhagic infarcts, etc. 

Place the lung upon a wooden surface and incise with a single 
stroke from apex to base, commencing at the convexity (laterally) 
and passing to the entrance of the large vessels. The color of the 
cut surface is to be determined at once ; note the amount of blood 
and the character of the fluid on squeezing ; microscopic examina- 
tions of scrapings can be made ; look for cavities ; the shape of 



INTESTINES. 119 

consolidated areas; determine specific gravity of the consolidated 
area. A hemorrhagic infarct or portion of apoplectic lung will 
sink in water as well as the lung of croupous pneumonia. Dissect 
out the bronchi. Never forget to weigh the organs and to make a 
written description as soon as they have been thoroughly examined. 
In order to make more room for the examination of the abdom- 
inal cavity the attachment of the diaphragm to the ribs on the 
right side can be cut and the liver turned over into the right 
thoracic cavity. Later on this also gives a favorable opportunity 
for the examination of the gall-bladder, ducts, and portal vessels. 

IX. Spleen. 

This is the first organ to be examined in the abdominal region. 
Introduce the hand below the diaphragm, in the left hypochron- 
driac region, and grasp the upper surface of the spleen with the 
hand, allowing the fingers to overlap upon the edge. By the exer- 
tion of a small amount of force the spleen can readily be brought 
to the median line of the body, still attached, however, by the 
splenic artery. Examine along the course of this vessel for 
supernumerary spleens. Detach the spleen and remove from the 
body. Before an incision is made into the organ examine the 
capsule, which may be thickened ; cut transversely from the ante- 
rior to the posterior surface ; look for Malpighian bodies, trabecular 
of connective tissue, tumors, caseation, miliary tubercles, etc. JSTote 
especially the consistence of the spleen and the amount of blood 
exuded. Infarction of the spleen is quite common, and the amyloid 
reaction would be more frequently demonstrated if a routine prac- 
tice of applying LugoPs solution were carried out. 

X. Intestines. 

Cotton is frequently placed in the rectum by the undertaker or 
nurse. Do not mistake this for anything abnormal. 

Tie two strings around the rectum and cut in between them ; 
then grasp the free end (the one away from the anus) and sever the 
mesenteric attachment, following up the sigmoid flexure, descend- 
ing colon, transverse colon, and ascending colon, and taking in 
about a foot of the ileum. Two circular bands are again applied 
around the ileum and an incision made between them. The 
intestines are then removed to the sink and the water allowed to 



POST-MORTEMS. 

run through them from the end of the small intestine, the s}::_ 
beix_ eniently introduced into the end of the small intestine 

:.".'. . :: _ .r ~:"uTr: :.:;_-■. ' ::. ^ T - „s:i '..-- ~~\ :-: > n: '. i.^-: :">:•:! ; :-e": 
and the matter that is Trashed has been carefully examined, the 
intestine ie opened with the enterotome. The rule is fco cut along 
the attachment of the mesentery, this being especially applicable 
to the small intestine. because the Peyers patches are situate! 
directly opposite the mesenteric attachment, and the curling of the 
intestines when opened, in case the mesentery has not been par | - 
- is not sc marked ; the small intestine is then removed up 
- the duodenum and washed in a si mil ar manner and again opened 
along the mesenteric attachment. 

XI. Semilunar Ganglion and Adrenal. 

The semilunar ganglia of the solar plexus are situated in front 
of the crura of the diaphragm, close to the adrenals, around the 
ooeliac axis, and at the root :: the superior mesenteric arte 
The adrenals are best removed attached to the kidneys, care being 
taken not to injure them. 

XH. Kidney. 

The kidney is easily found by making a nick with a knife in 

the perhonenni just ver the situation of the ureter where it g s 

r the brim of the pelvis, and following up the ureter, removing 

the loo- tiss - with the hand. The kidney may be imbedded in 

a large amount '~ ~-~ :: displaced. 

The kkinev is held in the left hand, the Lilum being toward 

the palm of the hand, and the :. rrity upward. A brain knife 

or large cartilage knife is held in the right hand and the kidney 

- Beted, care being taken not to continue the incision so far down 

- 1 1 injure the hand. In order to avoid this the incision may be 

- - - .-„- the kidney then being- inverted, the incision is 

carried upward away from the palm of the hand. In case the 

kid: - -ompletely cut through, the knife will it betw 

the thumb and the index finger if the kidney be properly held. 

The relation of the pyramids to the cortex is carefully examined 
(norm::. tisas to 1 I .-:■ capsule is then stripped off. takj _ 
■ - - : I' tht rtieal snbstan . at the 

same time. The external surf, : :ne kidney is examined es 

" - -. _ sf£ an readily be seen ? 



LIVER. 121 

and in opening a cystic kidney be careful that the liquid does not 
injure the eyes or soil the linen, as when the kidney is opened the 
liquid in the cyst is under pressure and may squirt several feet. 

Tumors of the kidney, especially fibroid, are quite common. In 
•order to determine the consistence of the kidney the cut section is 
pressed between the thumb and index-finger. 

XIII. Organs of Generation. 

By means of a circular incision close to the bony parts the 
organs of generation may be removed entire by cutting all of their 
attachments without injury to their component parts. 

XIV. Stomach. 

The stomach is preferably opened along the greater curvature by 
means of the enterotome, the incision being carried up into the 
oesophagus about three inches. In case poisoning is suspected, the 
oesophagus and the portion of the duodenum just below the pylorus 
should be tied, and the entire organ with its contents removed, 
placed in a clean jar, sealed, and saved for further examination 
either by the expert or yourself. The mucous membrane may be 
washed by means of dipping a sponge in water, holding it about 
six inches above the stomach, and making gentle traction upon the 
sponge so as to allow the water to flow over the stomach. The 
membrane should never be rubbed with the sponge. 

XV. Liver. 

The liver is measured, weighed, and incisions are made through- 
out its entire length. 

A duct can often be easily followed by making a nick in it, and 
introducing a piece of broom-whisp or a grooved director in the 
direction in which you desire to dissect. This is especially useful 
in the ureters and the ductus choledochus communis. Squeezing 
the gall-bladder after the duodenum has been laid open will often 
cause bile to pass out, and the papilla, the ending of the common 
bile-duct, can thus be demonstrated. In case of suspected stenosis 
or stoppage of the duct by a gall-stone, it is better not to practise 
this, as valuable information can frequently be obtained by exami- 
nation of the mucous membrane of the duct beneath the constric- 
tion when it is unstained with bile — which may be caused to be 
l^assed by the increased pressure. 

9 



122 POST-MORTEMS. 

XVI. Pancreas. 

The pancreas is now to be removed. This is readily accom- 
plished by remembering that it is closely in connection with the 
central portion of the duodenum. Do not mistake the splenic 
artery for the duct. Also remember that the pancreas is naturally 
a hard organ to the touch. Hemorrhages, inflammation, degenera- 
tion, stones, tumors, etc., may be found. Fat necrosis should 
always be thought of, as it is a cause of sudden death, such cases 
frequently coming under the head of Coroner's cases. 

XVII. Aorta. 

The aorta is opened throughout its entire extent. Do not mis- 
take the normal opening of the intercostals for anything patho- 
logical. 

XVIII. Skull. 

In order to expose the cranial cavity, an incision is made over 
the vertex and down to the bone from the base of one mastoid 
process to the other. If the hair is long it should first be parted 
in this direction, and the cut, after the first nick in the skin,, 
should always be from within outward. The knife will then cut 
between the hairs, and not across them as when the cut 'is made in 
the opposite direction. The scalp is then reflected backward and 
forward, a piece of cotton being placed over the eyes and nose in 
order that they may be protected. It may be necessary to use the 
knife in loosening the scalp ; if so, care should be exercised that it 
does not slip on the smooth surface of the bone and the operator's 
hand be injured. The circular or the angular incision through 
the bone can now be made, the latter being preferable in all private 
cases, as there is less danger of causing any disfigurement after the 
head is sewed up. 

The Circular Method. The saw cut is made in a line runnings 
circularly around the head, starting about half an inch to au 
inch above the ophryon and ending at the top of the inion. It 
will thus be seen that the posterior incision is lower than the 
anterior. This line will cross the temporal muscle about an inch 
above the external auditory meatus aud slightly obliquely. This 
muscle is then divided in this direction on both sides. The 
beginner can mark out the line with a lead -pencil. Skulls are of 
very unequal thickness, those of the colored race being especially 



REMOVAL OF THE BRAIN. 123 

thick. Different portions of the same sknll differ markedly, 
even on opposite sides at corresponding points. The thinnest por- 
tion is usually in the squamous portion of the temporal bone. The 
head is placed on a block, the body being well drawn np toward 
the head of the table, the left hand is wrapped with a towel and 
the head steadied while the sawing is being carried on. Unless 
there is a suspected fracture of the sknll, the sawing should be 
made only to the internal plate, which should next be broken by 
a chisel and hammer. A bucket is placed on the floor under the 
head in order to receive the blood and cerebro-spinal fluid ; a 
blunt hook is introduced beneath the frontal bone, and traction is 
made in the direction of the body. If the dura is adherent, or it 
the bones have not been well separated, considerable force is neces- 
sary, and if used the skull-cap may come away suddenly and injury 
to the hand of the operator may result. If the dura be very 
adherent, a spatula or the end of a dissecting knife can be used to 
separate it from the bone. 

The Angular Method. The only difference here is that an angle 
is made just about the external auditory meatus. The rule for 
making this angle is to cut through the temporal muscle in both 
directions so that the knife and saw will escape the ear. In re- 
moving the skull-cap it is very necessary that the angles be well 
sawed through and broken, and that it should be done carefully, 
as most brains are injured at this point. 

The longitudinal sinus is next opened by means of scissors. Do 
not mistake the Pacchionian granulations which may be present for 
a new growth such as tubercles. The dura is next cut by means 
of a blunt-pointed pair of scissors in the line of the original 
incision. The falx is next divided anteriorlv as near to the crista 
galli as possible, care being taken that the olfactory lobes are not 
injured. The dura is then thrown backward (posteriorly) over the 
occipital bone. One end of the frontal lobe is then gently raised, 
and in case a portion of the dura mater fall over and hide the 
olfactory bulbs, it can be removed. With the end of a scalpel the 
olfactory bulb is shelled out from its position on the ethmoid. 
The same is done on the other side. The ophthalmic artery and 
the optic nerve are cut as close as possible to their entrance into 
the optic foramen. Remember now to secure the pituitary body 
attached to the brain, for later on it will be too late, as the strain 
that is put on the infundibulum readily causes it to break. This can 
be readily done by cutting the dura covering-in the sella Turcica 



124 POST-MORTEMS. 

with a sharp knife close to the bone at all points, except posteriorly 
near the infundibulum, care being taken not to go in too deeply, as 
otherwise the gland itself may be injured. Scissors are then used 
to shell out the mass, the remaining portion of the dura is cut 
with the scissors and the hypophysis cerebri is free, except at its 
point of attachment to the brain. The internal carotids are then 
cut as long as possible. This remark is applicable to all the 
nerves and vessels of the brain. The third, fourth, fifth, and 
sixth pairs of nerves are cut in their order. The tentorium cere- 
belli is then cut on each side as close to the temporal bone as pos- 
sible. The remaining nerves are then divided. The left hand is 
then placed so as to support the occipital lobes, and a long, slender 
knife is introduced as close as possible to the cut wall of the for- 
amen magnum, and the cervical portion of the cord is cut in as 
much of a transverse direction as possible. The vertebrals are 
then cut, and the fingers of the right hand are used to shell out 
the cerebellum. The brain is then removed, resting upon the left 
hand, to a place of safety. A towel rolled up in the form of a 
turban makes an excellent resting-place for the brain. 

Dissection of the Brain. 

The brain is first carefully examined on its external surface, 
taking care not to forget the examination of the fourth ventricle, 
and the circle of Willis, including the course of the middle cerebral 
arteries lying in the fissure of Sylvius. This will also give you an 
opportunity of examining the island of Reil and the retro-insular 
convolutions. The brain is then put on its basal surface with 
the frontal and occipital lobe in a direction transverse to the table. 
This is done for the reason that afterward the incisions are to be 
made transversely to this line or parallel to the edge of the table. 
The top of the left hemisphere is grasped by introducing the 
thumb into the longitudinal fissure, and allowing the fingers to 
rest upon the convexity. The corpus callosum is then exposed, 
and the knife is introduced into the anterior genu in the neighbor- 
hood of the anterior cornu of the lateral ventricle, and a concave 
incision is made to the posterior cornu, care being taken not to 
injure in any way the floor of the lateral ventricle. The amount of 
fluid and its character are noted. Corpus striatum, optic thalamus, 
choroid plexus are then examined. The same is done on the right 
side ; the knife is then introduced into the foramen of Monro, and 



DISSECTION OF THE BRAIN. 125 

the anterior fornix is laid forward. If it is desired to examine for 
the fifth ventricle an incision directly in the median line maybe made 
in the septum lucidum. The body of the fornix is carried back ; 
then examine the corpus finibriatum, lyra, the anterior, posterior, 
and middle commissures, corpora quadrigemina, the pineal gland, 
the commencement of the iter e tertio ad quartrum ventriculum. 
The crura are then cut across, joining at an angle in the median 
line. The cerebellum is then removed, and an incision is made in 
the median line dividing the hemispheres into two. Through 
each of the four pieces of the cerebrum incisions are made verti- 
cally about a quarter of an inch to three-eighths apart, and all 
pathological changes are carefully noted. The cerebellum is cut 
in the same manner so as to expose the arbor vita?. The pons, 
medulla, and the commencement of the spinal cord may also be 
cut transversely, but this portion of the brain is preferably hard- 
ened in Miiller's fluid previous to section, which is best accom- 
plished by the preparation of a microscopic slide. 

Section- — as modified by Blackburn from the original plan of 
Meynert — may be made as follows : 

The brain is placed with its base upward and the cerebellar 
end toward the operator. The cerebellum is lifted up and the 
pia mater is cut through above the corpora quadrigemina, around 
the crura, and along the inner margins of the temporal lobes until 
the middle cerebral arteries are reached. The Sylvian fissures are 
now opened to their entire extent, the opercula are raised, and the 
insular lobes exposed to their limiting furrows. 

The apices of the temporal lobes are now raised, and, with the 
knife held nearly horizontally, their junction with the base is cut 
through until the anterior extremities of the descending cornua 
are opened. The knife is now inserted into the descending horn, 
and the incision is carried backward as far as the posterior angle 
of the insula, or even some distance beyond it, severing some of 
the convolutions at the posterior extremity of the Sylvian fissure. 

The next incision is made to separate the basal piece from the 
posterior extremities of the frontal lobes. It connects the anterior 
boundaries of the islands and opens the anterior horns of the ven- 
tricles. The incision may be a slightly curved, transverse one, 
connecting the anterior border of the islands ; or, by a little care 
and a double crescentic cut, the exact boundaries of the convolutions 
may be followed. 

The cerebellum is now raised and the knife is entered at the 



126 POST-MORTEMS. 

posterior angle of the island, and the incision is carried along the 
outer limiting furrow until it meets the cut previously made through 
the anterior border. Care must be taken to keep the knife in the 
anole between the roof of the ventricle and the basal ganglia, to 

O CO/ 

avoid injuring the latter. The basal piece is now lifted until the 
anterior crura of the fornix and the septum lucid urn may be severed, 
and the basal section thereby completed. 

The basal piece thus separated includes the island of Reil, the 
basal ganglia, the crura, pons, medulla, and cerebellum. The 
brain-mantle includes the convolutions, the corpus callosum, and 
fornix, and the olfactory tracts. 

The cerebellum may be separated from the brain-axis by cutting 
through its peduncles, and the lobes may be incised as in other 
methods. The basal ganglia, pons, and medulla are best examined 
by transverse incisions. The brain-mantle may be incised, if 
desired by Pitres' method, or hardened without further section. 

Virchow's Method. 

Virchow's method of dissecting the brain is used by many 
pathologists. It differs from the first method given, mainly in 
the section of the hemispheres ; the opening of the ventricles, and 
the dissection of the cerebellum and basal parts being about the 
same in both methods. 

After opening and examining the ventricles an incision is made 
in each hemisphere, extending outward and downward from the 
outer angle of the lateral ventricle to the pia mater of the lower 
part of the convexity. The portion thus turned outward is now 
divided into wedge-shaped pieces by incisions made from within 
outward to the pia mater, leaving the membrane to hold the parts 
together. The remainder of the dissection is practically the same 
as that already described. 

The method employed by Hamilton of injecting the vessels of 
the brain ( Text-book of Pathology, vol. i., p. 06) is as follows : 

The brain, freed from the dura, but covered by the pia and 
arachnoid, is next weighed and the vessels at the base at once 
injected with Midler's fluid, prepared according to the following 
formula : 

Strong. Weak. 

R. — Potass, bichrom. 45 parts, 3 percent. 

Sod. sulph 20 " 1 " " 

Water to make .... 1000 parts, 100 " " 



Hamilton's method of hardening brain. 127 

A bulky round earthenware basin with an earthenware lid must 
be in readiness, as the hardening is to commence at once. Fix a 
large canula into each of the internal carotids and tie it in with 
thin waxed twine. Fix another canula into one of the vertebrals, 
tying the vertebral opposite. Previous to fixing the canulae into 
the vessels, attach a piece of strong rubber tubing to each of the 
former, a foot and a half long. See that this is done before tying 
them into the vessels, as it is difficult to do so afterward. Place 
the brain, with the three canulae iuserted in its vessels, in the round 
earthenware basin, and in order to take the weight of the canulae 
off the vessels, allow the tubes to hang over the edge. Fix the 
rubber tubes to the connecting tubes represented in Fig. 54 
(b 17 6 2 , 6 3 ). The common tube, a, is in communication with a tank, 
which can be elevated or depressed. 

Fig. 54. 




Into the tank a large quantity of Midler's fluid is poured, and 
it is elevated to a height of about four feet. The stopcock at- 
tached to the tank is gradually turned on, so as to allow the 
Muller's fluid to percolate slowly through the organ. In order 
to give the fluid free play, care should be taken to place the 
canulae in the natural direction of the vessels and to see that their 
points are not pressing upon the walls. 

The first Midler's fluid which flows out contains blood, and 
should not be again employed ; but the subsequent injections can be 
made with the same Muller's fluid over and over again. It usually 
runs through very quickly, and the tank should be replenished at 
least every day for a week, or oftener if it is found convenient. 

The brain should always be freely supported by an excess of 
Muller's fluid, and there should be an overflow vessel into which 
the waste may escape. The fluid should be capable of being 
removed from this vessel without disturbing the brain or the 
position of the canulae. If the tank is replenished daily for a 
week it is usually sufficient; but, if convenient, the injection may 



128 POST-MORTEMS. 

be continued for a fortnight. The longer it is continued the better 
will the organ be hardened. It may be finally left in the Miiller's 
fluid for from two to three months, or even longer. The organ is 
not injured by time, and some of the most beautiful brains will be 
found to be those which have been in the Miiller's fluid for five or 
six months. The hardening process must not be hastened if thor- 
ough success is desired. 

While hardening it should not be padded to keep it in position. 
The best means of retaining its proper contour is to leave it in a 
plentiful excess of the liquid, aud its position should be occasion- 
ally changed. When cut into after being toughened in this way 
it presents a truly beautiful appearance. 

The following method is, however, more easily carried out, and 
gives most excellent results : 

An open jar, bucket, or wash-basin is one-quarter filled with ab- 
sorbent cotton, and Miiller's fluid is added until the vessel is about 
one-half filled. The brain, after being removed from the body and 
weighed, is carefully placed in the centre of the vessel and more 
fluid is added, until the brain is well covered. The vessel con- 
taining the brain is then placed in a refrigerator. If this be done 
there is no danger that the brain will decompose, even in summer, 
or if the arteries have not been injected or an incision made into 
the ventricles. The position of the brain is altered on the next 
day and the fluid changed. The removal of the fluid can best be 
accomplished by means of a siphon, the whole of the fluid never 
being removed. 

The fluid is changed again on the third day, then every other 
day for three successive times, twice a week for the next three 
weeks, and once a week for the next three weeks. 

The brain can then be thoroughly washed and put into alcohol 
of 80 per cent, strength ; or the Miiller's fluid can be prepared 
after the fifth or sixth week with one-fifth alcohol, then with one- 
quarter, one-third, one-half, and finally three-quarters alcohol, 
when the brain can be kept for several months until it is trans- 
ferred to the alcohol of 80 per cent, strength. 

Instead of Miiller's fluid a 2 J per cent, solution of the bichrom- 
ate of potassium may be employed. 

Giacomini's method is well adapted for the macroscopic study of 
the brain ; but, on account of the employment of the zinc chloride, 
the tissue is rendered useless for microscopic work. If the speci- 
men be a brain tumor, a small portion of the tumor can be placed 



METHOD OF HARDENING BRAIN. 129 

iu a hardening fluid for microscopic use, and the process then car- 
ried out for the hardening of the specimen. 

The brain, in as fresh a state as possible, is put into the liquor 
zinci chloridi of the U. S. Pharmacopoeia. The brain will be 
found to float at first, and should be turned several times the first 
day. On the second day the pia and the arachnoid should be 
removed. They have been employed up to this time in preserving 
the shape of the brain, but would afterward become firmly adherent 
to the cortex, and Avould be removed later on with much difficulty 
and often with injury to the brain. 

The membranes should be removed while the brain is under 
water or wdrile floating in the fluid. 

The brain is left in the fluid about six to ten days. It is then 
well washed with water and put for ten days or two weeks in 95 
per cent, alcohol. 

The brain is next removed and placed in glycerin for some ten 
days more. After this the brain is placed in some absorbent 
cotton, exposed to the air, in a dark place free from dust. 

Any exudation should be carefully removed, and when none 
appears (which will be in several weeks to as many months) the 
Outside is to be well coated with the best mastic varnish by means 
of a soft cameFs-hair brush. 

The brain frequently becomes flattened on the surface upon 
which it rests. Well packing with absorbent cotton and change 
of position will frequently prevent the distortion. 

Do not forget to label your specimens as soon as removed, nor 
forget that as the jar is uncovered the fluid will evaporate, and 
unless renewed the brain may be greatly damaged or even spoiled. 

The removal of the brain in a child is much more difficult 
than in the case of an adult ; first, because the brain is much softer, 
and second, because the dura is adherent to the cranial bones. 
These two factors add to the difficulty of the task, but there is one 
that makes it more easy — namely, that the sutures are not ossified 
together. The brain in a newborn child is so soft that it is almost 
impossible to take it out without injury. A good method is to lay 
the child for a short while upon ice upon which some salt has 
been sprinkled, in order that the brain may be hardened by the 
cold. I have secured the best results by placing the child in a 
large basin or tub of water, and the conducting of the final opera- 
tions here, while the body is held under the water by an assistant. 
Instead of ordinary water you may use a solution of salt. Add a 



130 POST-MORTEMS. 

half-bucketful of common salt to four or five bucketfuls of water ; 
this makes the solution slightly above the specific gravity of the 
brain substance, and there is much less danger of injury to the 
occipital lobes if the brain be taken out in this fluid. You may 
make exactly the same kind of incision as in the case of the adult. 
The scalp is much more easily removed than in the adult. The 
sutures are not joined, and the fontanelles are plainly to be seen. 
"With a small saw, saw through the frontal and occipital bones 
where ossification has already occurred : the rest of the cutting 
can usually be done with a pair of scissors or a knife. You then 
cut on each side of the longitudinal sinus and bend the bones to 
the side until they break and the brain is exposed, covered by the 
pia and arachnoid. 

When you have sawed the bones, the body should be, preferably, 
in the salt solution. It is held by your assistant, and you remove 
the brain as in the adult, first, however, removing the falx cerebri 
and longitudinal sinus. You next press the brain back and remove, 
with great care, the frontal lobes, with the olfactory lobes ; now 
cut the optic nerves, remove the pituitary body and the vessels, 
and expose the base. Cut the nerves and vessels long and sever 
the spinal cord as low down as possible. "When the tentorium 
cerebelli and falx are cut through, you can push the brain out upon 
the fluid. Its specific gravity will cause it to float, and if you 
desire to harden it, a good plan is to place the jar filled with 
Mliller's fluid under the brain. You can get the organ in the 
hardening fluid without much of the water or salt solution passing 
out. Afterward change the Miiller's solution for a fresh supply. 

Examination of the Eyes. 

For this purpose the orbital plate of the frontal bone is broken 
through by means of a hammer or chisel, care being taken not to 
injure the optic nerve at its entrance into the optic foramen, the 
remaining portion of the eye and the nerve being well protected. 
The pieces of bone are then removed with the forceps and the cut 
end of the optic nerve is grasped with the fingers or forceps and 
the nerve dissected out. The capsule of Tenon and fat are then 
removed, and an incision is made in the sclerotic, posterior to the 
conjunctival attachment. This is best done by means of a very 
sharp knife, as the tissue is extremely tough. A circular incision 
is then made around the entire eye, and the fundus is exposed. It 



EXAMINATION OF THE UPPER AIR-PASSAGES. 131 



is then placed in Midler's fluid for further study. A piece of dark 
cloth or cotton dipped in ink is then placed in the remaining por- 
tion of the eye so that no disfigurement may be noticed. The 
cavity is then packed with cotton. 

In order to expose to view the upper air passages (nasal, 
pharyngeal, laryngeal, and accessory cavities) Harke 1 (quoted by 
Hektoen) recommends the folloAving 
ready procedure : 

After removing the brain in the or- 
dinary manner, the soft parts are re- 
flected anteriorly down to the root of 
the nose, posteriorly down below the 
foramen magnum. Then the floor of 
the skull is divided in the median line 
by means of a keyhole saw from the 
nasal bones in front to the occipital 
foramen behind, keeping as nearly as 
possible in the median line. Now the 
two skull halves are separated by means 
of a broad chisel and mallet, and as the 
nasal and pharyngeal cavities come into 
view, the pieces of mucous membrane 
may be cut across with the knife or 
scissors so as to prevent further tear- 
ing. With the hammer and the chisel 
the axis may be divided. The two 
halves of the skull are still connected 
by the nasal bones, the maxillary pro- 
cess of the upper jaw and the bony pal- 
ate ; strong traction will separate these 
bony connections without injury to the 
soft parts, and the lateral halves of the 
skull and spine will yield sufficiently 
to permit inspection of the tract clear 
down to the vocal cords. Usually the 
median incision passes a little to one 

x t m shaped piece, f g, and h i, can be 

side, but the partitions between the sawed through the bone, so that at 

accessory cavities are readily cut awav f 1 ™ * ase they win gain entrance 

J J •> to the foramen magnum. 

with strong scissors ; the maxillary 

sinuses as well as the frontal, sphenoid and ethmoid cavities, are 

also easily opened from the median surfaces. 




The primary incision, a, b, or the 
circular incision, c, e, d, the longi- 
tudinal incision being from e to b. 
If it be desired to remove the cord 
attached to the brain, the posterior 
flap of the scalp can be divided by a 
vertical incision, and the wedge- 



1 Berliner klin. Wochenschrift, 1892, No. 30. 



132 POST-MORTEMS. 

Iii order to remove the spinal cord the body is placed on the 
abdomen, and the head is allowed to hang over the table. With 
a long sweep of the knife an incision is made from the occipital 
protuberance to about the fourth lumbar vertebra. Considerable 
time should then be taken in cleaning the muscle and fascia from 
the vertebra, as otherwise the teeth of the saw are apt to become 
clogged with this material. This can be accomplished with a rub- 
bing motion of an old knife or chisel. If the case be one in which 
no disfigurement at all is permissible, a circular incision, with the 
radius at the inion, can be made from shoulder to shoulder, 
and the skin dissected away. This gives abundant room for the 
introduction of the instruments used for the removal of the cervical 
vertebra?. Care must be used as to the angle at which the saw 7 is 
inclined. This should be at thirty degrees from the spine, and 
about half an inch on each side. There is danger, in case this 
angle be not adopted, that the saw will either not enter the canal 
or will enter into the place where the cord lies, and thus injure it. 
After the sawdng has been accomplished in the dorsal region a pair 
of bone-nippers is used to pry up the portions of vertebra which 
have been sawed through, and the dura mater is exposed. Then 
the sawing can be continued in both directions until the entire 
vertebral canal is open, except that the atlas and axis had better 
be removed by means of the bone-forceps. The dura and the 
spinal nerves are then cut below the corda equina, and the ante- 
rior and posterior portions of the dura are grasped with the forceps 
or fingers, and by means of pushing to one side or the other the 
nerves are cut as they enter into their foramina ; the only diffi- 
cult portion being at the foramen magnum, where the dura can 
best be cut loose from the bony cranial cavity after the removal of 
the brain. 

After the cord has been removed the dura is to be opened in a 
longitudinal direction, and transverse sections about an inch apart 
are to be made through the cord and its membranes. The nerves 
hold the cord to the dura, and a favorable opportunity is thus 
given for the examination of the cord with the naked eye or with 
a hand-lens. The vessel containing the cord should be placed, 
in summer, on ice and the fluid changed in the same manner as 
for the brain. The best results are gotten by hanging the cord 
by means of a string in a long museum jar filled with fluid. 
Both the brain and cord can, of course, be placed in the same 
vessel. 



AUTOPSIES ON THE NEWBORN. 133 

To Preserve Urine. 

1. Add a few drops of chloroform to the bottle containing the 
sample of urine, or f5j of a 5 per cent, alcoholic solution of 
resorcin. 

2. Allow the precipitate to settle to the bottom of the vessel, 
draw off the supernatant liquid with a pipette, and then add a satu- 
rated solution of boric acid. 

Either of the above methods will preserve urine for a long time 
as far as the tube-casts are concerned. 

Sputum. 

Sputum should be put into a " fired bottle." This is prepared 
by taking a glass-stoppered bottle and pouring a little alcohol in 
it ; then agitate and ignite. Allow the alcohol to burn out and 
stopper while hot. 

Other organs removed from the body should be first washed in 
running water until free from blood. They should then be placed 
in a suitable jar containing equal parts of 95 per cent, alcohol and 
pure water, care being taken to supply sufficient fluid to well cover 
the specimen. A piece of cheese-cloth should then be placed on 
top, so that in case of evaporation the fluid will be supplied to the 
uncovered portion of the specimens by means of capillary attrac- 
tion. In case there occurs much cloudiness or the slightest odor, 
the alcohol should be immediately renewed. 

If it is desired to preserve the natural color of the organs the 
following solution is well adapted for this purpose : 

R — Sod. sulph. | 

Sod. chloride Y aa 100 parts 

Potass, chlorate J 

Potass, nitrate .... . . 10 " 

Water to make . . . . . . . 1000 " 

The fluid should be changed several times, or a saturated 
solution of boric acid may be employed, to which 50 per cent, 
glycerin can be added with good results. 

Autopsies on the Newborn. 

According to Virchow (translated by Smith), the following 
regulations are in force in Prussia for the guidance of medical 



134 POST-MORTEMS. 

jurists in conducting post-mortem examinations for legal purposes 
in newborn children : 

I. Determination of Maturity and Period of Development. 
In the post-mortem examination of newborn children special 
attention is to be directed to the following points : 

In the first place, the signs indicative of maturity and period of 
development must be looked for. 

These are : The length and weight of the child, the condition of 
the general integument and of the umbilical cord, the length and 
state of the hair of the head, the size of the fontanelles, the 
diameter of the cranium (longitudinal, transverse, and diagonal), 
the condition of the eyes (membrana pupillaris), the state of the 
cartilages of the nose and ear, the length and condition of the 
nails, the transverse diameter of the body at the shoulder and hips ; 
in male infants, the condition of the scrotum and position of the testi- 
cles; in females, the condition of the external organs of generation. 

Finally, we must examine the size of the centre of ossification 
(if present) in the inferior epiphysis of the femur. For this pur- 
pose, the knee-joint must be opened by means of a transverse 
incision below the patella, the joint fully bent and the patella 
removed ; thin layers are then to be cut from the cartilaginous 
end of the femur, until the greatest transverse diameter of the 
centre of ossification (if present) be reached ; this is to be measured 
in millimetres. 

Should the condition of the foetus be such as clearly to prove 
that it was born before the completion of the thirtieth week, it is 
not necessary to proceed further with the examination, unless the 
magistrate distinctly requires it. 

II. Determination of the Question whether the Child has 
Breathed. If it shall appear that the child has been born after 
the thirtieth week, the next step is to ascertain whether it has 
breathed during or after birth. For this purpose the respiration 
test must be applied, and the proceedings conducted in the fol- 
lowing order : 

a. Immediately on opening the abdominal cavity the position 
of the diaphragm is to be ascertained, with reference to the cor- 
responding rib, and, on this account, in newborn children, the 
abdomen is always to be opened first, and afterward the thorax 
and cranium. 

b. Before opening the thorax a ligature is to be placed around 
the trachea above the sternum. 



AUTOPSIES ON THE NEWBORN. 135 

c. The thorax is then to be opened, and attention must be paid 
to the degree of dilatation of the lungs, and their position depen- 
dent upon such dilatation, particularly with reference to the peri- 
cardium. The color and consistence of the lungs should also be 
ascertained. 

d. The pericardium is then to be opened, and its condition and 
that of the heart, externally, are to be ascertained. 

e. The cavities of the heart are then to be opened, and their 
contents to be examined, aud the condition of the heart in other 
respects is to be determined. 

f. The larynx and that portion of the trachea above the ligature 
are then to be opened by means of a longitudinal incision, and any 
contents are to be examined. 

g. The trachea is to be divided above the ligature and removed, 
together with all the organs of the thorax. 

h. After removing the thymus gland and the heart, the lungs 
are to placed in a capacious vessel filled with clean, cold water, in 
order to test their buoyancy. 

i. The lower part of the trachea and its subdivisions are to be 
laid open and examined, especially with reference to their contents. 
j. Incisions are to be made in both lungs, and notice taken 
whether any crepitant sound be heard, and also with reference to 
the amount and quality of the blood issuing from these cut surfaces 
on slight pressure. 

h. Incisions are to be made in the lungs below the surface of the 
water to see whether any air-bubbles rise from the cut surfaces. 

I. Both lungs are next to be separated into their lobes, and 
these are to be divided into several small pieces, the buoyancy of 
each of which is to be tested. 

m. The oesophagus is to be opened and its condition ascertained. 

n. Lastly, in cases where it is suspected that air cannot gain 
access to the lungs, in consequence of the filling up of their cells 
and passages with morbid products (hepatization) or foreign sub- 
stances (mucus, meconium), the lung tissue is to be examined with 
the microscope. 

After the examination of the body is completed, all of the blood, 
fecal matter, etc., should be removed with a sponge from the 
thoracic and abdominal cavities, and any bleeding vessels tied. 
The organs can then be returned to the body, and a peck of bran 
or a roll of absorbent cotton introduced on their top. If any of 



136 POST-MORTEMS. 

the organs have been removed, fill in with old newspapers or 
towels. If bran is not at hand, a towel or an old sheet can be 
laid on top of the organs and the body sewed with continuous 
sutures, starting at the symphysis pubis and sewing from below 
upward. The stitches should be about three-eighths of an inch 
from the cut edge and about one-half of an inch apart, the one on 
the opposite side being not directly opposite, but one-fourth of an 
inch above and below it. The length of the thread is, roughly, 
twice the length of the part to be sewed. At the commencement 
and end tie with a good, strong knot. See that the edges are 
kept even, so that at the end puckering does not occur. The body 
is next washed, dressed, and returned to its proper place. If two 
persons are lifting the body, the lighter weight is obtained by 
holding the feet. 

Urine or aromatic spirit of ammonia will best take off the odor 
from your hands. This odor is usually gotten from opening the 
intestines. Ammonia (also the aromatic spirit) will remove iodine 
stains ; a weak solution of the hypobromite solution will remove 
carbo-fuchsin and other anilin stains from the hands. 

It is well to remember — 

That in warm weather the intestines are especially liable to 
undergo rapid decomposition when exposed to the air ; 

That a railway train or cart may pass over the body and there 
be no abrasion in the skin more than a brush burn ; 

That the color of organs is frequently changed when exposed to 
the air by the oxidation of the haemoglobin. Also that the sul- 
phide of iron frequently discolors organs after death, due to the 
sulphuretted hydrogen during decomposition precipitating the iron 
of the hsenioglobin ; 

That many signs of inflammation, especially of the mucous 
membrane, disappear after death. Remember that red flannel 
often colors the skin red ; 

That blood makes a good glue for affixing labels, and the blood 
of a person dying from hydrocyanic-acid poisoning makes a most 
excellent red ink which will keep for years without the addition 
of any preservative fluid ; 

And lastly, be honest. Everyone diagnoses lesions during life 
which are not found at the post-mortem. 



PART III. 

SPECIAL PATHOLOGY. 



There is no work in the English language that can be so thor- 
oughly recommended for the study of the lesions in special patho- 
logical anatomy as that of Osier's Text-booh of Medicine. 

The number of lesions that can affect any individual part is 
necessarily limited. The following plan will aid one in correctly 
diagnosing the lesions of any organ : 

Consider — 

1. The normal anatomy and histology of the part. 

2. Malformations, congenital and acquired. 

3. Parenchymatous changes. 

4. Interstitial changes. 

5. Blood changes. 

6. Inflammation. 

7. Infectious diseases. 

8. Tumors and parasites. 

9. Action of poisons. 

10. Post-mortem changes. 

11. Microscopic examination. 

12. Bacteriological examination. 

If you are given a specimen to diagnose, try to find out all you 
can about the person from whom it was removed, the condition of 
the various parts, and the reason for its removal. Failing in this, 
determine whether it is an organ, a tumor, or a tumor in an organ. 
If an organ, run over in your mind the lesions which are alone 
possible to be found in such an organ (such a list, for example, as 
is given under the heading of the Lung); e. g. y it would be absurd 
to think of a croupous pneumonia in a piece of liver, yet the 
action of the toxine elaborated by or through the pneumococcus in 
producing a parenchymatous degeneration should be considered if 

10 



138 SPECIAL PATHOLOGY. 

the lungs show croupous pneumonia. Then exclude those condi- 
tions which are inconsistent with the appearance of the specimen, 
e. g., if the intestines do not show anything wrong with the soli- 
tary follicles, typhoid fever need not be considered as being capable 
of demonstration from such a specimen. Xext group together 
those lesions which the specimen might illustrate, and by exclusion 
of what it is not, rather than by what it really is, you will often 
be able to make a diagnosis. Xaming a lesion which looks like 
the specimen is by no means so bad as not being able to even 
mention what the specimen really is. 

A lesion in one part of the body will often suggest an exam- 
ination for another lesion in another part of the body, e. g., if you 
find ulcerative endocarditis you will carefully examine the lungs, 
spleen, kidneys, and so forth, for hemorrhagic infarcts. There is 
often an association of lesions, e. g., in cerebral hemorrhage look 
for miliary aneurisms and atheroma of the vessels. It should 
constantly be borne in mind that a combination of lesions will 
often deceive you, e. g., acute yellow atrophy of the liver in a 
case preceded by pseudo-hypertrophic cirrhosis. 

There is no question so hard to answer as, How do you know 
that a specimen is such or such a thing ? Different persons will 
arrive at the same conclusion by different methods of investigation. 
Things which we think we know to-day may be shown to be false 
to-morrow. Tests which are at one time supposed to be infallible 
are seen to have exceptions which practically invalidate the tests. 

Brain. 

Gower's table of intra-cranial growths arranged in the order of 
their frequency : 

1 . Diathetic : tubercular and syphilitic. 

2. Sarcomatous : glioma, sarcoma, myxo-sarcoma. 

3. Carcinoma. 

4. Osteo-fibroid : fibroma, osteoma, osteo-fibroma. 

5. Miscellaneous : cholesteatoma, lipoma, vascular or erectile 
tumors, psammoma, neuroma. 

6. Parasitic : echinococcus and cysticercus. 

Exhibits. 

1. Glioma of the cerebellum. 

2. Aneurism of the basilar artery. 



BRAIN. 



139 



3. Rupture of a bloodvessel into the internal capsule. 

4. Extra-dural hemorrhage. 

5. Osteophyte of the falx cerebri. 

6. Abscess of the brain. 

7. Softening of the brain. 

8. Miliary aneurisms of the arteries of the brain. 

9. Atheroma of the circle of Willis. 

10. The brain of an idiot. 

1 1 . Hydrocephalus. 

Out of 646 cases collected by Gowers there were twice as many 
tumors of the brain in the male as in the female. The reason 
for this is not clear. There is no case yet recorded of a tumor 
appearing in a child before the age of six months. Tubercular 
tumors are especially liable to occur in children between the tenth 
and twentieth years. Tumors are less apt to appear in old age 
than in middle life. They are most common between the twentieth 
and fortieth years. Syphilitic tumors may come on in twelve 



Fig. 56. 




Hemorrhagic tumor of the pituitary hody. 

(From a patieut ;of Anders in the Philadelphia Hospital. Post-mortem by the author. 

Journal of Nervous and Mental Disease.) 



months after the initial jlesion, or there may be as long time 
elapsing as fifteen years after the initial lesion. The usual time 
is from five to eight Jyears. There is no doubt that the number 
of syphilitic tumors reported is entirely too small, because many 
may have entirely disappeared under appropriate treatment or are 
not correctly diagnosed. Tubercular and syphilitic tumors con- 



140 



SPECIAL PATHOLOGY. 



stitute the largest proportion of brain tumors found on the post- 
mortem table — 75 per cent, of all tumors belong here. 

Leaving syphilitic tumors out of the list, one-half of the re- 
mainder are tubercular and one-third of the other half sarcoma- 
tous. 

The cerebellum is much smaller in actual amount of brain tis- 
sue than the cerebrum, the tumors of the former being propor- 
tionately greater than those of the cerebrum. 

Tubercular tumors possess certain characteristics peculiar to the 
brain. A tumor in the brain may grow to the size of a hen's egg 
and be solitary or multiple. It may become encapsulated by being 
surrounded by fibrous tissue, and afterward become infiltrated 
with the salts of lime. It grows by the coalescence of smaller 
tubercular nodules. 

Fig. 57. 




Aneurism ol the basilar artery. 
(Trans, of the Path. Soc. of Phila., vol. xv.) 



Abscess of the brain may occur at any age, at any time of the 
year, and in either sex ; but it is more common in the male than 
in the female, the proportion being as 3 to 1. 

The cause of abscess is usually one or other of three kinds : 

First. Traumatic. The largest class with which we have to 
deal. 

Second. Access of micro-organisms through the channels which 
have more or less communication with the brain, such as the 
middle ear, necrosis of temporal bone, or through the nose. There 
was a case lately at the University Hospital in which abscess of 



SPINAL CORD. 141 

the brain followed an operation upon the nose. Several cases 
have been caused by the " oidium albicans" of thrush. 

Third. Access of micro-organisms by the blood. Cases com- 
paratively few. 

Abscess may be single or multiple. May communicate with the 
membranes or be entirely hidden within the brain substance. One- 
half or even two-thirds of the brain may be involved. They 
can often be diagnosed and localized (even the small ones) with 
comparative accuracy. 

Cerebral Hemorrhage. Familiarity with the brain and the 
distribution of its bloodvessels will indicate where hemorrhage is 
most likely to occur. Most damage is done by the rupture of 
arteries situated in the internal capsule. Apoplexy is the popu- 
lar term given to cerebral hemorrhage. 

Hemorrhages may be divMed into meningeal and cerebral ; the 
former meaning hemorrhage in connection with the membranes, 
and the latter restricted to hemorrhage in the brain substance. 
An extra-dural hemorrhage is very apt to be associated with frac- 
ture of the skull. 

It is not often that veins will rupture in health ; in suffocation 
veins are more likely to rupture than arteries. French patholo- 
gists find that minute aneurisms of the arteries precede hemor- 
rhages, and the minute hemorrhages are preceded by degeneration 
of the vessel walls and a giving way of the muscular coats. 

Hemorrhages may occur at all periods of life. They are more 
common in temperate climates than in warmer ones, and in winter 
than in summer, and in the male than in the female. Cases are on 
record in which entire families have been swept away by apoplectic 
attacks. The chief seat of the lesion is in the internal capsule. 
The opposite side of the body is affected. 

Spinal Cord. 

Exhibits. 

1. Normal cord imbedded in celloidin and impregnated with a 
neutral copper acetate solution as practised in Weigert's method. 

2. Syringomyelia. 

3. Locomotor ataxia. 

4. Disseminated sclerosis. 

5. Myelitis. 



142 



SPECIAL PATHOLOGY 



The descending tracts of the cord are the cross pyramidal tract, 
the direct pyramidal tract, the anterolateral tract, and the comma- 
shaped tract. 

The ascending tracts are the direct cerebellar tract, the postero- 
median tract, the postero-internal column or the column of Goll, 
the postero-external tract or the column of Burdach, the ascending 
antero-lateral tract or Gowers' tract, the posterior zone or 
Lissauer's tract. 

Spina Bifida. 

The term spina bifida is applied to a congenital defect in the 
union of the lamina? of one or more vertebra?, associated with 
malformation of the spinal cord or its membranes. 

The spinal cord and a large part of the brain are formed by the 
dorsal coalescence of the medullary folds. The fusion of these 
folds commences in the thoracic and extends into the cephalic and 
caudal regions. For a short time after coalescence the embryonic 
cord and superficial epiblast remain in contact. Gradually they 

Fig. 58. 




Case of spina bifida. The letters refer to the various anatomical parts 



become separated by the intrusion of connective tissue, some of 
which chondrifies and afterward ossifies to form vertebra? and 
inter-vertebral disks. In the early stages the cord has a longi- 
tudinal extent equal to that of the notochord, and this equality is 
maintained for some time after the closure of the medullary groove. 
Subsequently the vertebral column grows at a greater rate than the 
nerve-tube ; the result is that at birth the medullary cone at the 



ARTERIES. 143 

end of the cord is opposite the upper border of the second lumbar 
vertebra. [From Tumors: Innocent and Malignant, by J. Bland 
Sutton.] 

Heart. 

Pericarditis. An inflammation of the sac or serous covering 
of the heart. Inflammations of pericardium occur exactly as do 
inflammations of the pleurae or peritoneum. There is an out- 
pouring of serum with a large amount of clear fluid. You have 
to distinguish whether it is inflammatory in character or merely a 
serous exudate. Usually you soon have the formation of flakes 
of fibrin, which can be readily recognized by the naked eye. You 
may have a combination of the serous and fibrinous variety, or 
an organized mass, or an infiltration 'with salts of lime, or a 
variety in which pus is formed. There is a variety in which 
tubercular processes are set up. 

Exhibits. 

1. Cloudy swelling. 

2. Fatty infiltration. 

3. Fatty degeneration. 

4. Brown atrophy. 

5. Acute myocarditis. 

6. Chronic myocarditis. 

7. Aneurism of the heart. 

8. Cardio-mvomalacia. 



Hypertrophy and Dilatation. 

Acute endocarditis, chronic endocarditis, ulcerative endocarditis. 
ISew growths : Tubercle, syphilitic gummata, secondary cancers 
and sarcomas (rarely primary), fibroma, myoma, lipoma, and cysts 
of the echinococcus and cysticercus. 

Arteries. 

1. Acute arteritis. 

2. Chronic arteritis and atheroma. 

3. Endarteritis obliterans. 

4. Aneurisms. 



144 



SPECIAL PATHOLOGY 



Remarks. 

Cloudy swelling of heart is due to an inflammation which has 
lasted only a short time, or it is the precursor of fatty degeneration. 
One of the causes is high fever, as in scarlet fever, typhoid fever, 
or septicaemia. Macroscopical examination shows the heart in this 
condition to be friable, i. e.. easily broken with lingers, and it 
looks a- though it had been in boiling water. Under the micro- 
scope, the normal striation of the heart-muscle has been lost, and 
you seem to be looking at tke specimen through ground-glass, or 
it seems as if tke specimen kad been dusted with fine dust. Acetic 
acid will clear away tke cloudy condition and cause tke normal 
striation s and tke nuclei to reappear. 

Fatty infiltration to a slight degree is normal. To a larger 
degree it is found in persons wko are constitutionally inclined to 
obesity. Starts from tke outside. 

Fatty degeneration of tke heart follows hypertrophy, fatty 
infiltration, interference with oxygenization. etc. Starts from tke 
inside. 

Fig. 59. 




Brown atrophy of the heart. X 400. (Woodhead.) 
Muscle fibres broken up into short segments. Mounted unstained in Farrant's solution. 
The pigment is collected around the nucleus. In this condition the transverse striation is 
very plainly marked. 

Brown atrophy. A decrease in tke size of tke cells, or a 
diminution of their number. Tke keart is pigmented and smaller 
tkan normal, and tkere is a tortuous and shrunken appearance of 
tke coronary arteries. 

Myocarditis. Inflammation of tke muscle of tke keart. Acute 
or chronic. Occurs usuallv bv means of an extension from an 



KIDNEYS. 145 

inflamed neighboring part, as in pericarditis or endocarditis. In 
tlje chronic cases there is a proliferation of the connective tissue 
septa which dip down between the muscular fibres. 

Fig. 60. 




Fatty degeneration of the muscle of the heart. X 350. (Ziegler.) 

Endocarditis. Inflammation of the endocardium, chiefly 
situated in the valves. The great majority of cases are due to the 
presence of micro-organisms. 

Tumors of the heart are of rather rare occurrence. There 
may be tubercle, syphilitic gummata exactly similar to gummata 
in other parts of the body, my omata, which are usually congenital, 
secondary carcinomata and sarcomata, fibromata, lipomata, and 
the cysts of the echinococcus and cysticercus. 

Arteries stand a great deal of inflammation, particularly in tuber- 
culosis. It has been well said that a person is as old as his arteries. 

Endarteritis obliterans occurs principally in syphilis. 

Aneurisms of the heart are rather frequent. Many cases are 
on record. They are usually preceded by degeneration of the 
heart-muscle. 

Kidneys. 

Exhibits. 

1. Stone in the pelvis of the kidney. 

2. Horse-shoe kidney. 

3. Picture of bilateral double ureters. 

4. Acute parenchymatous nephritis. 

5. Chronic parenchymatous nephritis. 

6. Chronic interstitial nephritis. 

7. Amyloid kidney. 

8. Hsematoma of the kidney. 

9. Cysts of the kidney. 

10. Lobulated kidnev of a child. 



146 SPECIAL PATHOLOGY. 

A great deal of confusion is caused in the description of patho- 
logical lesions of the kidney on account of the multiplicity of 
terms employed. All lesions may be classified under the struc- 
tures affected in three divisions : 

I. Epithelial (parenchymatous). 
II. Connective tissue (interstitial). 
III. Vessels (vascular). 

Bear in mind that there is practically no such thing as a pure 
form of nephritis, and that the condition which predominates gives 
the name to its lesion. For example, when we speak of paren- 
chymatous nephritis we do not mean that the epithelial cells alone 
are affected without any involvement of the connective tissue. We 
may also describe a kidney as one of chronic parenchymatous 
nephritis in which interstitial changes are beginning to predomi- 
nate. Any portion of the uriniferons tract may be affected pri- 
marily, hence the names glomerulo-nephritis, etc. Cysts, the adhe- 
sions of the parenchyma to the capsule and increased consistence 
are the great features of connective tissue changes. The yellowing 
of the cortex, due to fatty degeneration of the epithelial cells, 
is the striking feature of a parenchymatous nephritis, along with 
an obliteration of the smaller bloodvessels, and the primary in- 
crease in the relation of the cortex to the pyramids. 

Fatty and Contracted Kidney. Red Granular Kidney. 

Contraction of kidney, secondary. Contraction of kidney, primary. 

Size seldom below normal. Size, below normal; often reduced 

to one-half or one-fourth. 

Capsule adherent only in places, Capsule adherent, thickened. Sur- 

seldom thickened. Surface lobu- face granular, rough. Color, red 

lated, often smooth. Color, pale, or grayish red. 

mottled or yellow. 

Cysts usually large, and seldom Cysts usually small-sized and nume- 

numerous. Pelvis rarely dilated. rous. Pelvis often dilated. 

Arterial changes are rare, or not Arterial changes (endarteritis, or 

pronounced. peri-arteritis) almost invariably 

present. 

Cortex often normal in size. Atro- Cortex always much atrophied. 

phy very late. 

Renal epithelium much swollen, Renal epithelium never desquamat- 

desquamating freely, often in a ing, though it may undergo fatty 

state of fatty degeneration, but degeneration (necrosis), and be- 

cells always visible. Compound come diminished in size and 

granule cells. partly lost. 



DISEASES OF THE GENITO-U R1N AR Y TRACT. 147 

Fatty and Contracted Kidney. Red Granular Kidney. 

Tube-casts, epithelial, dark granu- Tube-casts, hyaline, pale, granular, 
lar, and containing compound and waxy, but never containing 
granule cells, and later fat-glo- epithelial cells, 
bules. 

[From Philadelphia Hospital Reports, vol. i. ; by Dr. Formad.] 

Diseases of the Genito-Urinary Tract. 

Malformations and Deformities. 

Lesions of the kidney affect either the parenchyma or the con- 
nective tissue. Usually both are concerned in the process, and there 



Fig. 61. 




Bilateral complete double ureters. 

(From a patieut of Professor Hirst's, in the University Hospital. From a photograph by 

Dr. Wallace. Post-mortem by the author.) 

is therefore no such thing as a pure parenchymatous nephritis 
or a pure interstitial nephritis. Different names are often given to 
the inflammatory process according to the particular portion of the 
tubules effected. In interstitial nephritis cysts are frequently seen. 
A great many are formed by occlusion of the urinary tubules ; such 
cysts are usually small, because the pressure upon the cyst will 
before long be equal to that of the blood, and consequently the 
cyst-formation stops. Perhaps several will run together, and in 
this way larger ones may be produced. These cysts are called 



148 



SPECIAL PATHOLOGY. 



primary, and they contain different materials in different cases. 
This may be : 

1. A gelatinous substance. 

2. True urine. 

3. Blood serum. 

4. Blood, making the so-called blood-cyst, or, if larger, the 
hsematoma. 

5. A colloid or mucoid material. 

6. A cheesy material resulting from degeneration of the epithe- 
lium. 

Cysts may also be secondary. Such are often seen at birth, 
and mav occur in the situation of the normal lobulation of this 



Fig. 62. 




)\ 




- 



Hematoma of the kidney. 
Specimen in the Museum of Morbid Anatomy. University of Pennsylvania. 

organ in intra-uterine life. They may also follow gummata. A 
specimen shown has two large cysts. One is full of a clear fluid, 
which now is probably alcohol, as the specimen has stood in this 
fluid for some time ; below this is a larger cyst filled with a different 
fluid, probably resulting from degeneration. Such a cyst may 
have a stone as its starting-point. Another specimen shown has 
a smaller cyst, resulting probably from interstitial nephritis. 



Forms of Renal Calculi (after AVoodhead). 

1. Reddish or brownish-yellow uric acid in the form of gravel, 
or rounded, smooth masses the size of a pea or larger. 

2. Calculi filling the pelvis and calyces of the kidney, irregular 
and branchiug, with a somewhat rough surface, and composed of 
phosphates and uric acid or urates. 




D 





A. Leucin balls, and tyrosin sheaves and rosettes. 

B. Spermatorrhoea. Morning urine. Spermatozoa, lymph bodies, and spermatic crystals are seen. 

C. Aente parenchymatous nephritis, of several weeks' standing. Hyaline, epithelial, and granular 
casts, with epithelial-, blood-, and pus-celis. 

D. Chronic parenchymatous nephritis, with fat in the urine. The casts here are of a markedly 
degenerative variety, and various forms of the products of fatty degeneration are seen, as margaric 
acid crvstals and cholesterin. 



(From Alias der Mikroskopie am Kravkenbetle, by Dr. A. Peyer.) 



MALFORMATIONS AND DEFORMITIES. 149 

3. Oxalate of lime calculi ; small, smooth, or mulberry masses, 
dark -gray or purple in color, and extremely hard. 

4. Carbonate of lime calculi are found in the kidneys of old 
people. When pure they are usually yellow and hard. 

5. Phosphate of lime calculi. 

6. Triple phosphate of ammonium and magnesium may be 
found deposited on any of the various other forms of calculi or 
on an inflamed surface, especially where there is decomposition of 
the urine. 

7. Cystin calculi are rarely met with. 

8. Xanthine calculi. 

9. Bile-pigment calculi are sometimes met with in people suffer- 
ing from icterus, especially in the case of newborn children. 

It is rarely that we find these stones made up entirely of one 
substance ; usually the centre is made up of one kind of material, 
and upon this nidus there is the successive deposition of other 
salts. Sometimes a foreign body, as a hair-pin, may form in the 
bladder the nidus, and very frequently the centre of a stone is 
made up of uric acid. Stones in the kidney and bladder occur 
more frequently in localities where the water contains an excess 
of inorganic salts. Here the calcium carbonate calculi are most 
common on account of the limestone found in this section. 

The size of calculi depends entirely upon the case ; no rules can 
be given. They may be single or multiple. If multiple, they are 
apt to be small ; if single, large. There may be a dozen or more. 
They are of all shapes ; those in the pelvis are usually very 
irregular in outline. An irregular stone in the pelvis of the 
kidney of a man aged ninety is shown in the demonstration. You 
can very readily understand how such a stone could give rise to 
the great pain which accompanies such cases, and which frequently 
leads the surgeon to operate. Another specimen shown is 
composed of a basis of oxalate of calcium, about which the triple 
phosphates have accumulated. Such stones are very irregular in 
shape. The majority of kidney stones pass into the bladder, 
where they may afterward become agglutinated. Other varieties 
form here in the first place. 

Calculi form in other cavities besides that of the kidney and 
in the urinary bladder. They are sometimes found in the duct of 
Stenson, which comes from the salivary gland, and in the pan- 
creatic duct. Occasionally they are found in the prostate, especially 



150 SPECIAL PATHOLOGY. 

iu old age. Rarely they are found in the prepuce ; but other so- 
called stones in this situation are usually calcified smegma. 

Urinary calculi are most frequent in the young, 60 per cent, 
occurring before the age of twenty-six. They. are relatively more 
common after sixty. 

Diseases of the Ureters. 

Malformations. We not uncommonly meet with the existence 
of double ureters. Usually it will be found that in a case of 
this kind the ureters join before entering the bladder, and this 
usually happens at the middle third or below it. It is very easy 
to overlook this fact, and a careless observer would say they were 
separate throughout their course. In order to aid the dissection 
of the ureters you may make use of the following plan : Take a 
piece of grass from a broom, make a small incision into the tube, 
well up where you can easily see it, and through this pass the 
grass into the bladder. You can now with ease dissect up the tube 
upon this guide. Sometimes the double ureters remain separate 
and empty into the bladder without joining. In this case you will 
be able to detect four papillae upon the mucous membrane of >the L 
bladder. Such a case occurred at the University Hospital some 
time ago, and you can see the condition in Fig. 61. 

The ureters are very often occluded from a number of causes, 
such as tuberculosis and syphilis, which cause ulceration and sub- 
sequent cicatrization. As a result of the occlusion, the ureters 
above the seat of obstruction will become greatly dilated, some- 
times four, five, or six times the normal size. 

Diseases of the Bladder. 

Fungoid growths are in this situation quite common, especially 
the papilloma. They may break down and ulcerate. 

Cystitis. This is a very common condition, and in the chronic 
forms leads to great thickening of the bladder wall. The appear- 
ance of the interior in the chronic cases is not unlike that of 
the left ventricle. The urine finds pockets in the thickened 
mucous membrane, and these pockets often lodge stones ; they 
may extend for an inch or more into the bladder walls. You 
can very readily understand that a stone in the bladder may be 
detected witli a sound one day and the next become buried in 
one of these pockets, and the surgeon be unable to find it upon 



EXTRA-UTERINE PREGNANCY. 151 

the day of operation. I recall a case of this character at the 
University Hospital. All the symptoms of stone were found 
the day before operation, but when the patient came before the 
class none could be detected by the sound. The operation was 
continued, however, and a large calculus taken out. There 
are a great many diseases of this tract which belong especially 
to the genito-urinary surgeon. Yon, of course, know how 
common is stricture, and that an enlarged prostate is of very 
frequent occurrence in old people. These parts are very often 
malformed. Hypospadia and epispadia are often seen, and result 
from a failure in union in early life. The scrotum is sometimes 
divided, and this may lead to a mistake in sex. I remember a 
case of this kind where the true sex was not discovered until the 
sixteenth year. 

The penis may be malformed and perhaps hid in the scrotum ; 
such cases promise much by early operation, for when the organ 
is released it generally grows afterward to its normal size. 

Diseases of the Uterus and Tubes. 

You have so often heard of these from the chair of Gynecology 
that it is only necessary to review a few of the most important : 

Malformations in size are not uncommon. Here is a specimen 
showing a uterus so small that it can hardly be seen. You will 
notice that the tubes and ovaries are of about normal size. Such 
a condition is a frequent cause of sterility. 

Tumors are very common. It is rare for a woman, especially 
a colored one, to go through life without one ; they are usually 
fibroids in the uterus. 

Cancers may occur at any part of the tract. 

Extra-uterine Pregnancy. 

There can be no doubt of the great frequency of this condition. 
It is still a cause of many deaths, but of late years the gynecolo- 
gists have done much to diminish the number of cases going on to 
a fatal termination. Dr. Formad used to say that some years ago 
he would have as many as fifteen cases come under his care in the 
course of a year, while of late this number was reduced by 50 or 
60 per cent. Women do not go about now as they did some years 
ago, with an abdomen filled witli blood from a ruptured extra- 



152 SPECIAL PATHOLOGY. 

uterine pregnancy, and so they no longer come under the observa- 
tion of the Coroner's physician. The condition is diagnosed early 
usually, and operation will very often save the life of the patient. 
An interesting case of extra-uterine pregnancy that came under my 
observation last year very well shows the benefit that could have 
resulted from an operation. Here the pregnancy had occurred the 
summer before and had progressed until the gestation sac had 
become as large as a small fist ; it was upon the right side. The sac 
was firmly attached to the caput coli, and in the umbilical region 
a very interesting state of aifairs was found. Here it was noticed 
that two coils of intestine were connected by a narrow band of 
fibrous material, which resembled very much a carpet thread. 
Underneath this band was another loop of intestine which had 
become twisted upon itself over the band, and a volvulus was pro- 
duced. You can very readily see that an operation to relieve this 
condition would be an easy one ; it would only have been neces- 
sary to cut this narrow band. As it was, it produced the death of 
the patient. 

An extra-uterine pregnancy is well shown in this specimen. 
You will notice that the small sac is filled with blood ; this is the 
usual condition ; you will notice upon the post-mortem table it is 
often impossible to find the embryo after rupture has taken place. 
The amount of blood lost in rupture is sometimes very great, and 
perhaps no condition produces as much shock as does the rupture 
of an extra- uterine gestation sac. The whole subject of extra- 
uterine pregnancy is shrouded in mystery. The cause is still 
unknown. It is at present not known if the ovum is impregnated 
within the uterus or while yet in the tube Lawson Tait is of the 
opinion that extra-uterine pregnancy occurs because there has been 
a previous salpingitis which has denuded the tube of its ciliated 
epithelium, and there is, consequently, obstruction to the passage 
of the ovum into the uterus. This is probably not the case, 
because in many cases the epithelium is normal. Sutton believes 
that the tube is closed, but that cilia are still present and normal. 

A peculiar condition is that known as the blighted ovum or the 
apoplectic ovum. Here a mass of clotted blood containing a cyst, 
the whole being about the size of an English walnut, is passed 
from the uterus. This usually occurs about the second or third 
month and frequently produces quite extensive hemorrhage. 

A small embryo may, instead of passing downward into the 
uterus, pass into the abdominal cavity through the abdominal 



RESPIRATORY TRACT. 



153 



ostium, and thus may lead to peritonitis. If such a condition does 
not occur before the fifth or sixth week it probably cannot take 
place, for at this time the ostium becomes closed. It is an inter- 
esting fact that extra-uterine pregnancy is not reported in the 
lower animals ; you should remember this, and if you meet with a 
case it will be well worth recording. 



Respiratory Tract. 

1. Nose. 

Larynx. 

Trachea. 

Bronchi. 



2. Lungs. 

Abscess. 

Anthracosis. 

Apoplexy. 

Atelectasis. 

Bronchiectasis. 

Bronchitis. 
Acute. 
Chronic. 
Capillary. 

Brown induration. 
Cirrhosis. 
Collapse of. 
Congestion of. 
Cysts. 

Emphysema of. 
Fat embolism. 
Gangrene. 
Hemorrhage. 
Inflammations of. 



GEdema. 

Parasites. 

Phthisis. 

Acute. 

Chronic. 
Pleurisy. 
Pneumonia. 

Fibrinous-croupous. 

Lobar. 

Catarrhal or lobular 

Desquamative. 

Caseous. 

Purulent. 

Interstitial. 
Syphilis. 

Tumors. 

Primary. 
Secondary. 



Exhibits. 

1. Tubercular and syphilitic ulcerations of the larynx. 

2. Phthisis (with slide, showing tubercle bacilli). 

3. Anthracosis. 

11 



154 



SPECIAL PATHOLOGY". 



4. Croupous pneumouia (with slide). 

5. Secondary cancer of the lung. 

6. Calcareous tuberculous nodules in the luno;. 

7. Emphysema (with slide). 

8. Atelectasis (with slide). 

9. Hemorrhagic infarct. 

In reviewing your work for the examinations you will find that 
a very excellent plan is to take some medical book, such as Prof. 



Fig. 63. 




Scheme of a lung lobule. 

PA and PV, pulmonary artery and vein; BR, bronchiole; I, infundibulum ; av, air- 
vesicles ; I S, inter-lobular septum ; P P, pleura ; L B, lobular bronchus. (Landois and 
Stirling.) 



Ashhurst's Surge?*y, and, turning to the index, to run over the 
contents in alphabetical order. Pass each word before your mind, 



RESPIRATORY TRACT. 155 

and, if you are not familiar with its meaning, turn to the text and 
review it. 

The Nose. Malformations of this organ are quite common. 
Perhaps the most frequent is a deviation of the septum to one side 
or the other. In the condition known as cyclops, in which there 
is only one eye, the nose may be absent, or, if present, exist as a 
snout. In this condition there has been a failure to develop or an 
improper fusion of the embryonal layers. Quite frequently you 
will see persons upon the street with the nose much enlarged and 
with dilated vessels. This may be due to a congenital dilatation 
of the vessels — an angiomatous condition — but is more frequently 
the result of excesses, especially of alcohol, and is known as 
acne rosacea or rhinophyma. The nasal chambers are divided 
into the olfactory and respiratory portions ; each of these has 
its peculiar epithelial lining. The nasal mucous membrane is 
subject to all the disorders seen in other mucous surfaces. It 
may be the starting-point for diphtheria or scarlet fever, just 
as the exposed mucous membrane in the case of extrophy of the 
bladder may be. Do not forget that tuberculosis may start here 
primarily, and the lesions of this membrane in such cases are very 
often overlooked. Many of the cases of chronic nasal discharge 
will show the bacillus in the material from the nose if such 
be examined. At the post-mortem this cavity can be exposed 
posteriorly by cutting away the sphenoid bone in a triangular 
manner. Tumors in this situation are common, and a great deal 
of attention has been paid to this subject of late. It is a peculiar 
fact that hypertrophies and tumors of the nasal cavities sometimes 
produce serious reflex symptoms. Many interesting papers have 
been written upon this matter, especially abroad, where reports 
have been published of a large number of such cases occurring 
among school-children. For example, it was found that a child 
might by reason of a nasal growth become, as indicated by a 
photograph, really a high-class idiot. After removal of such a 
tumor this child would rapidly reach a condition in which the 
symptoms of idiocy were no longer to be noticed. In some schools 
the children have been examined, and sometimes, after removal of 
a nasal tumor, a child which before had stood at the bottom of the 
class would progress very rapidly toward the top. The reason of 
this reflex disturbance is not known. It has been thought that 
such growths may prevent the normal interchange of gases sup- 
posed to exist between the frontal sinus and the nose. Whatever 



156 SPECIAL PATHOLOGY. 

the cause may be, there is no doubt that most remarkable reflex 
disturbances may occur, and even epilepsy and asthma are pro- 
duced by these nasal growths. 

Polyps are quite common. They are often other growths that 
have undergone myxomatous degeneration, but occasionally are 
myxomatous from the start. Fig. 21 shows a growth pro- 
truding from the nose ; it is supposed to be taken from a nun's 
face — for these growths usually only reach such a large size in 
persons who live in convents or where the surgeon is not 
allowed to operate. Picking of the nose is a frequent cause for 
the formation of these growths. These polyps are often very 
vascular, and on removal an extensive hemorrhage is not infre- 
quently produced, and in consequence has been followed by 
death. 

A purulent discharge from the nose is caused by a great many 
diseases. This is a prominent symptom in grippe, and follows a 
number of the infectious diseases. Gumma and the lesions of 
tuberculosis may occur in this situation, and, as you know, glan- 
ders is common in the horse. As a rare infection of the nasal 
mucous membrane, I may mention that of the common gad-fly, or 
Gastrophilus equi. Sometimes this fly, which yon may have seen 
while driving through the woods, will lay its eggs in the nose, and 
from these numerous larva? will be hatched, which burrow into 
the tissue. Death is rapid and most horrible. 

Diphtheria, Syphilis, and Tuberculosis. 

Diphtheria of the larynx was formerly thought to be different 
from the process occurring in the pharynx ; but we now know that 
they are both caused by the same bacillus. Diphtheria in the 
larynx usually results from extension from the pharynx, and differs 
from the pharyngeal form in being more superficial. This occurs 
because the structures here are more dense and hard, while in the 
pharynx there is much lymphoid tissue. Fig. 22 shows the con- 
dition very well. You will notice this mass of false membrane 
which extends far down into the trachea. Such a growth of false 
membrane would offer considerable obstruction to the passage of 
air ; portions may be taken into the smaller tubes and set up a 
catarrhal pneumonia. You may have the formation of a false 
membrane from other causes besides diphtheria ; it may be caused 
by the inhalation of hot air or steam, and the membrane thus 



DIPHTHERIA, SYPHILIS, AND TUBERCULOSIS. 157 

formed may so closely resemble that of diphtheria that you cannot 
tell them apart by a gross examination. It is sometimes difficult 
to tell syphilis from tuberculosis as it occurs in the larynx ; yet it is 
often quite important to be able to differentiate between them. If 
there is any rule for this, it is that the lesions of tuberculosis are 
more apt to be multiple and found upon the posterior surface of 
the larynx. Now, why should they be upon the posterior part ? 
Because during sleep the patient rests upon his back, and the 
sputum, by gravity, falls to the posterior part of the larynx and 

Fig. 64. 




Elastic fibres in sputum. (R. v. Jaksch.) 



is not coughed up, as it is in the waking hours ; consequently the 
bacilli act upon these parts. A large class of tumors is found in 
the region of the vocal cords. Such a tumor may lead to quite 
serious results by falling down and so obstructing the air-passages. 
Foreign bodies sometimes reach the larynx and cause like symp- 
toms. A jack-stone, for instance, may be taken into the larynx 
and cause obstruction. Cancers and sarcomas are found. Cancers 
usually involve the larynx by extension from the oesophagus. 
They usually infiltrate the surrounding tissues to a considerable 
extent, and it is for this reason that extirpation of the larynx is 
such a difficult feat when performed for a malignant growth. 

Bronchi. Inflammatory conditions of the bronchi are fre- 
quently set up by micro-organisms or through the irritation of 
dust, etc. 

Abscess and gangrene are usually studied together ; they result 
from septic embolism usually caused from some suppurative area 
elsewhere in the body, the micro-organisms of which are carried to 
the lung and set up either gangrene or abscess according to the 



158 SPECIAL PATHOLOGY. 

cause. A case was shown at a meeting of the Pathological 
Society in which gangrene of the lungs had followed necrosis of 
the tibia following amputation. "We cannot quite tell why in one 
case gangrene should result and in another abscess. Abscess may 
be either acute or chronic, and may rupture either iuto the bron- 
chial tubes or into the pleura. In the former condition the 
patient may expectorate large quantities of pus. Not infrequently 
an abscess of the pleura involves the lung by eating its way in. 

The inhalation of dust of various kinds may produce an inflam- 
mation of the lung. "Workers in stone get a disease known as 
calcicosis ; workers in iron, siderosis or grinder's phthisis. Many 
of the mineral substances contain silicon, and there is a disease 
known as silicosis. Anthracosis is quite common among the 
persons who work in coal dust ; it produces the disease known as 
coal-dust phthisis. 

If in your practice you should be consulted by a patient who 
works in coal dust, and he comes to you with the symptoms of 
lung disease, you may get valuable help by examining the palms 
of his hands, noticing whether there are spots of coal pigment. In 
anthracosis the entire lung is of a black color, and usually shows a 
considerable increase of connective tissue. Of course, true phthisis 
is not caused by the inhalation of coal dust ; it can only occur 
when the bacillus gains entrance to the lung, but the irritation 
produced by the particles of carbon predisposes the lung to the 
action of the bacillus. True phthisical cavities are formed in such 
a lung, and in a specimen shown you will notice large cavities in a 
lung black with carbon. There is always in these forms of 
phthisis the formation of large amounts of connective tissue, and 
for this reason the course is chronic. 

Hemorrhages of the lung, sometimes called pulmonary 
apoplexies, are caused by active congestion, which may follow 
rapid running and exercise ; they may prove fatal. Some peculiar 
cases have occurred in which the pulmonary apoplexy has followed 
a lesion in the pons or medulla ; in such a case the pulmonary 
hemorrhage may be upon the opposite side to that in which the 
cerebral injury has occurred. 

Atelectasis is of two forms : 1. That known as the foetal 
atelectasis, in whicli the lung-tissue has never expanded. 2. That 
due to obstruction to the passage of air, which causes the collapse 
of a part of the lung of small or large area. 

Bronchitis. There are several varieties of inflammation of the 



DIPHTHERIA, SYPHILIS, AND TUBERCULOSIS. 159 

bronchial tubes, to which a number of names are given, such as 
acute, chronic, capillary, and so forth. In the capillary form the 
very small bronchioles are involved, and there is almost always 
more or less catarrhal pneumonia present. 

In brown induration the lung is hard from excessive quantity 
of connective tissue and is dark from pigmentation. There is an 
iuterstitial process of new connective-tissue formation going on. 

Congestion of the lung may be most marked, and it is often 
impossible on the post-mortem table to tell it from the lung in the 
early stages of pneumonia. 

Emphysema produces a marked change in the appearance of 
the lungs ; the air-vesicles are distended. It is quite common to 
find this condition in old people. It may be produced by violent 
efforts in expiration, as in the cough of whooping-cough. The 
condition is easily recognized : the lung will be enlarged and 
light, floating high up when thrown upon water ; it has a char- 
acteristic feel, crackling when you press upon it, and you can 
with very little force cause the air to come to the surface, where it 
appears as a bleb. 

Pat Embolus. The lungs are sometimes seen to contain 
emboli and fat ; this may follow fracture of some bone and may 
occur in diabetes. 

Infarctions. The majority are of the hemorrhagic variety. 
They present the peculiar wedge shape with which you are familiar, 
with the base toward the periphery. Ansemic infarcts sometimes 
occur. 

In oedema of the lungs the tissue is infiltrated with serum ; 
this occurs especially in the dependent portions ; it comes on very 
often just before death, and is common in old age and in many of 
the acute diseases. 

Pleurisy is nearly always an accompaniment of pneumonia, and 
here is acute. The chronic forms of pleurisy are now thought to 
be due largely to tuberculosis. The sero-fibrinous exudate is the 
most common upon this membrane, and quite frequently leads to 
extensive adhesions between the parietal and visceral layers. 

Pneumonia. A most important subject. The most important 
forms are the croupous and catarrhal. 

Croupous pneumonia is called lobar pneumonia, and catarrhal 
pneumonia lobular pneumonia. 

In croupous pneumonia there are four well-marked stages : 1 . 
Engorgement. 2. Red hepatization. 3. Gray hepatization, and 
4. Resolution. 



160 



SPECIAL PATHOLOGY. 



In the first stage the lung is much engorged with blood, and 
enlarged on this account. In the stage of red hepatization the 
luns; is really enlarged, is heavy and sinks in water. A cut sur- 
face is granular and looks like marble ; this is due to the small 
plugs of fibrin which stand up from the air-vesicles, and are 
capable of being scraped off with a knife and examined under the 



Fig. 65. 




Fibrinous casts, from a case of pneumonia. They also occur in bronchial croup. 

(R. v. Jaksch.) 



microscope. In the stage of gray hepatization there is something 
of a cheesy change, and the afTected areas are light from fatty de- 
generation and from anaemia ; the leucocytes are also greatly in 
excess. You have seen during the year numerous fresh specimens 
showing the lung in the different stages of red hepatization, and 
you will be able to recognize the small plugs of fibrinous material 
in the air-vesicles. 

Syphilis of the lung is rather a rare condition. TTe generally 
find in this a fibrous change which may or may not be associated 
with tuberculosis. 

Tumors. Many of the benign growths are found here, and 
also the primary and secondary carcinomata and sarcomata. 



TABLE SHOWING DIFFERENCES BETWEEN CROUPOUS AND CATARRHAL 

PNEUMONIA. 

Croupous. 

1. Whole lobe usually affected; 
hence the name lobar pneu- 



Catarrhal, 

Lobules affected, hence the name 
pneumonia. Syn., 



monia. Syn., Fibrinous ; 
pleuro-pneumonia. 
2. Xo areas of healthy lung tissue 
in affected lobes ; other lobes 
healthy, but congested. 



lobular 
Broncho-pneumonia. 

Irregular areas of lung tissue in 
various stages of degenera- 
tion intermingled with normal 
lobules. 



ALIMENTARY TRACT. 



161 



Croupous. 



3. Lung weighs much more than 
normal. An entire lobe may 
sink in water. 



4. Microscope, 
to stage. 



Varies according 



5. An extensive fibrinous exudate 

on the pleura covering the 
affected area. 

6. Pneumococcus found in nearly- 

all cases. 

7. Usually at base and posteriorly. 



8. Usually one-sided. 

9. On section the lung varies ac- 

cording to stage, the marbled 
appearance being especially 
striking in the third stage. 
Notice the fibrinous plugs. 

10. Sputum, so-called rusty sputum. 

11. Lung of same age. 



Catarrhal. 

3. Lung weighs but slightly more 

than normal. An entire lobe 
will float on water, though 
small portions may sink. 

4. Microscope. Three zones : cen- 

tre, a small bronchus ; mid- 
dle, a desquamative area con- 
taining many cells, little or 
no fibrin ; outer, zone of con- 
gestion. 

5. Exudate slight, if present. 



6. Pneumococcus rarely found. 

7. Usually at the termination of 

the smaller bronchioles and 
anywhere in the lung. 

8. Usually on both sides, and asso- 

ciated with other diseases. 

9. On section the lung is congested. 

Small angular irregular 
patches, the central portion 
being the oldest, are seen. 

10. Sputum more purulent. 

11. Diseased portion of lung varies ; 

some spots old, some new, the 
oldest being around the bron- 
chioles; healthy tissue be- 
tween affected areas. Caseous 
pneumonia, really a form of 
catarrhal pneumonia, is due 
to the action of a toxine, as 
from the tubercle bacilli. In 
phthisis there may be small 
areas of croupous pneumonia. 

12. Capillary bronchitis and catar- 

rhal pneumonia are, patho- 
logically, practically the 
same. 



Alimentary Tract. 

Exhibits. 

1. Typhoid ulcers. 

2. Tubercular ulcers. 

3. Tubercular peritonitis. 



162 



SPECIAL PATHOLOGY. 



4. Dysenteric ulcers due to the amoeba coli. 

5. Lipoma of the large intestine. 

6. Appendicitis due to a pin. 

7. Tubercular appendicitis. 

8. Streptococci appendicitis. 

9. Gastric ulcer. 

10. Stomach from a case of arsenical poisoning. 

11. Stomach from a case of carbolic acid poisoning. 

12. Scirrhus cancer of the pyloric end of the stomach. 

13. Secondary cancer of the liver. 

14. Fatty liver. 

15. Acute yellow atrophy. 

16. Abscess of the liver. 

17. Gall-stones. 

18. Cirrhosis of the liver. 

19. Amyloid liver. 

20. Echinococcus cyst of the liver. 

21. Leukemic liver. 



Typhoid Ulcer. 
1. Direction often longitudinal. 



2. Edges undermined, ragged, and 

can be floated out on water ; 
thin, vascular, and composed 
of mucosa and submucosa — 
red. 

3. Floor smooth and vascular. 



4. Peritoneal surface unaltered, 

except that it may be in- 
flamed. No thickening and 
no gray or yellow patches. 

5. Mesentery unaltered ; glands 

enlarged, vascular, pink, and 
softened. 



Tubercular Ulcer. 

1. Direction transverse (frequent- 

ly). This distinction is not 
so characteristic as is some- 
times held. 

2. Edges not undermined; thick, 

prominent, nodulated, ter- 
raced, or sloping — pale or 
red, composed of tissue infil- 
trated with tubercular nod- 
ules. 

3. Floor nodular, irregular, thick- 

ened, irregular, vascular, 
with pale or yellow points or 
areas. 

4. Peritoneum thickened — small 

yellow or gray points in the 
floor of ulcer running along 
the lines of the lymphatics. 

5. Mesentery thickened at its at- 

tachment to the bowel ; 
glands enlarged, firm and 
gelatinous on section, or case- 
ous. 



ALIMENTARY TRACT. 



163 



Typhoid Ulcer. 

6. Perforation more common both 6. 

by separation of slough and 
by direct extension of the 
ulcerative process. Small 
opening by which the feces 
may escape. Peritonitis. 
Hemorrhage may occur dur- 
ing either of these processes. 

7. Microscopically: A specific 7. 

inflammation affecting the 
adenoid tissue; bloodvessels 
distended, and increased vas- 
cularity of the mucosa and 
submucosa. Dense masses 
of small round cells — lym- 
phoid cells and leucocytes — 
with some large multinucle- 
ated cells, the latter of which 
are derived directly from en- 
dothelioid cells. A line of 
demarcation is formed, and 
abscess results, beginning in 
the solitary glands and other 
lymphoid tissue of the mu- 
cosa and submucosa. 

8. Extension takes place laterally 8. 

or in depth. 

9. Heals by granulation, the thin 9. 

edges falling on to and unit- 
ing with the granulating floor 
of the ulcer. 
10. Leaves a smooth, often de- 10. 
pressed, pale, anaemic, or pig- 
mented cicatrix, covered by 
a layer of epithelium, but no 
gland tissue. Seldom breaks 
out afresh, relapses being due 
»to the affection of adenoid 
patches previously little dam- 
aged. 



Tubercular Ulcer. 
Perforation, peritonitis, and 
hemorrhage — all rare. 



Microscopically : A specific 
inflammatory affection also 
of the adenoid tissue and the 
mucous membrane, ending 
in caseation and connective- 
tissue formation ; vascularity 
of mucosa and submucosa; 
increase of connective-tissue 
cells and lymphoid cells ; 
tubular nodules, typical or 
caseating. It begins in the 
mucous membrane, and, like 
the typhoid lesion, is due to 
direct contagion or infection. 



Extension usually takes place 

laterally. 
Very rarely heals. 



Leaves a puckered cicatrix in 
which are gray or white nod- 
ules ; often breaks out afresh. 



[Woodhead's Practical Pathology, 3d edition, p. 455.] 



The finding of the typhoid bacillus, by culture and staining 
methods, and of the tubercle bacillus by culture, inoculation, and 
staining methods are the most important for diagnostic purposes. 



164 



SPECIAL PATHOLOGY. 

Fig. 66. 




I. Scheme of a liver-lobule. V. i, V. i, inter-lobular vein (portal) ; V. c, central or intra- 
lobular vein (hepatic) ; c, c, capillaries between both ; V. s, sub-lobular vein ; V. v. vena vas- 
cularis ; A, A, hepatic artery, giving branches, r, r, to Glisson's capsule and the larger 
vessels, and ultimately forming the vense vasculares at i, i, opening into the intra-lobular 
capillaries ; g, bile-ducts ; x, x, intra-lobular biliary channels between the liver cells; d, d, 
position of the liver cells between the meshes of the blood-capillaries. II. Isolated liver 
cells ; c, a blood-capillary ; a, fine bile-capillary channel. (Landois and Stirling.) 



Fig. 67. 



Fjg. 6S. 



CL 



L 





Human inter-lobular bile-duct. 

(Landois and Stirling.) 
a. Circular fibres, b. Cylindrical 
epithelium. 



A small extra lobe of the liver lying upon 
the gall-bladder, and connected with 
the right lobe by means of vessels and 
duct. 



ALIMENTARY TRACT. 

Fig. 69. 



165 







rmm 



Gastric ulcer in which perforation has occurred. The most common seat is posteriorly, 
near the pyloric end and lesser curvature of the stomach. (Specimen in the Museum of 
Morbid Anatomy.) 




**'C 



Common objects found under the microscope in the examination of the feces. (R. v. Jaksch.) 

a. Muscle fibres, ft. Connective tissue, c. Epithelium, d. White blood-cells, e.f.g.h.i.l. 
Various forms of plant cells, k. Triple phosphate crystals. The black dots represent various 
forms of micro-organisms. 

Fig. 71. 




Contents of the mouth. (R. v. Jaksch.) 

a. Squamous epithelium, ft. Salivary corpuscles, c. Fat-drops, e. Spirocheeta buccal is. 
f. Comma bacillus of the mouth, g. Leptothrix buccalis. h. i. k. Various forms of 
fungi. 



166 



SPECIAL PATHOLOGY. 



Parasites. 



Fig. 72. 



Fig. 73. 





Fig. ~4. 




Fig. 72. — Distoma hepaticum. (R. v. Jaksch.) 

Fig. 73. — Ascaris lumbricoides. (The larger one.) Female, one-third natural size ; head 
magnified. Male, one-third natural size. (Zieglee.) 
Fig. 74. — Gastrophilus equi. (Zieglee.) 

Fig. 75. 




Pediculus puhis, or crab-louse, with ova adhering to the hair. 
(Fenlayson ; drawn by Wilson.) 

Fig. 76. 




Filaria sanguinis hominis. (R. v. Jaksch.) 




Taenia saginata (mediocanellata). T. solium. Bothriocephalus latus. 

Head, x 10. Segments, natural size. Eggs, X 200. The head and first segments of 
the tenia saginata and of the tenia solium are reduced one-half. 




1. Ascaris lumbricoides (one-half natural size). 1*. Egg, X 180. 

2. Oxyuris vermicularis, X 2%. 2*. Egg, X 180. 

3. Trichocephalus dispar, X2%. 3*. Egg, X 180. 

4. Anchylostoma duodenale, X 2%. 4*. Egg, x 180. 

5. Trichina spiralis, X2%. 5*. Encysted trichina spiralis, X 30. 

6. Distomum hepaticum, X2^. 6*. Egg, X 180 

(From Atlas der Mikroskopie am Krankenbetle, by Dr. A Peyer.) 



PARASITES 



167 



Fig. 78. 



Fig. 77. 





Cysticercus from taenia solium removed Cysticercus of taenia solium with its head 

from its capsule. (Natural size.) It is sur- and segments protruded. The caudal sac 

rounded by an embryo sac. Head of hook- is seen. (Landois and Stirling.) 
lets can be seen. (Landois and Stirling.) 



Fig. 79. 




Encapsulated cysticercus from taenia solium, imbedded in a human sartorius. 
Natural size. , (Landois and Stirling.) 



Fig 




a, Trichomonas intestinalis. b, Cercomonas intestinalis (Bavainf). c, Amceba coli. 
d, Paramoecium coli. e, Monadines, living. /, Monadines, dead. (R. v. Jaksch.) 



168 



SPECIAL PATHOLOGY. 



The taenia echinococcus reaches its mature state in the alimentary 
tract of the dog ; the place where we find the larvae is both in man 
and in the lower animals, such as the hog, ox, sheep, rat. There- 
fore, the true worm does not grow in man ; merely the egg is hatched 
and the worm produced. These changes may be compared to those 
of the butterfly. The egg is laid by the butterfly (taenia echino- 
coccus), and is hatched into a worm (hydatid worm) ; the worm 
forms the cocoon (cyst) and is turned finally again into a butterfly 
(taenia echinococcus). 

Fig. 81. 

A- 




A. Mature tsenia echinococcus. 

B. Group of echinococci still adhering to the germinal membrane by their pedicles. X 40. 
C Invagination of the head into the caudal vesicle. X 107. 

D. Head is here protruded from the caudal vesicle. 

E. Rostellum, showing hooklets. X 350. 

F. Compressed form. 

G. Membrane of cyst- wall. 

H. Hooklets from Prof. Goodell's case. X 450. 

(A, from Cobbold ; B, C, D, E, from Bavaine, in Finlayson ; G, from Peyer.) 



The taenia echinococcus is a very small worm — only four to five 
millimetres in length. It has a head in which there are four open- 
ings surrounded by a rostellum, with a double row of hooklets. 
To this are attached three or four segments. The last segment is 
the one in which we find the eggs, which may number as many as 



PARASITES. 169 

five thousand. It is as long as two millimetres and seven-tenth 
millimetres broad. The dog passes out one of these segments con- 
taining the eggs, and the eggs are thus brought in some way in con- 
tact with the man or animal, and thus follows the entrance of these 
eggs into the body ; the outside portion of the egg is digested, 
and avo have the echinococcus, with its six booklets, in the alimen- 
tary canal. From this we may have a perforation of the alimen- 
tary tract, as the worm possesses amoeboid movement, and echino- 
cocci may be carried in the venous circulation, even passing the 
capillaries of the lungs, and thus entering the arterial circulation. 
Therefore we have the echinococcus ; not a tsenia, for that occurs in 
the dog. It gets into the liver, as it has done in the specimen 
which is shown you, and makes there a cyst, which is known 
as an echinococcus cyst. This cyst, lined with a membrane, is 
filled with a clear fluid which does not contain albumin, but which 



Fig. 82. 




Scheme showing the life history of the taenia echinococcus. 

may contain sugar, and later on we have what has been shown you — 
a proliferation of this embryo and an attempt at the formation of the 
taenia. If you could imagine the scolex with the segment attached 
it would resemble that which occurs in the dog. This cyst is 
lined with thousands and thousands of these little scolices. Soon 
there is produced from the parenchymatous layer a budding which 
is usually internal, but which may be external, and then we have 
what is called the daughter cyst, and we may have a granddaughter 
cyst, etc., produced in the same manner. So, you see, one of these 
eggs is capable of producing a cyst, and this cyst is capable of 
producing hundreds of others lined with millions of scolices, each 
one of which, if it gets into a dog, is capable of becoming a full- 

12 



17" 



SPECIAL PATHOLOGY. 



grown cestode. You see this is very different from the other 
tape-worm, as, in the tamia solium, for example, one egg, one 
tape-worm. (See Figs. 81 and 82.) 

According to Cobbold, one-sixth of the annual mortality rate in 
Iceland is due to some form or other of the echinococcus. 

Blood. 



Fig. 83. 




Blood from a case of tertian fever ; showing Plasmodium, leucocytes, eosinophile leuco- 
cytes, and blood plates. Stained by Aldeboff s method. (R. v. Jaksch.) 



Fig. 84. 




Rare forms of the Plasmodium. (R. v. Jaksch.) 



Fig. 85. 



■«|° 






p 




Blood, showing the Plasmodium a few hours after an attack of tertian fever. (R. v. Jaksch.) 



MISCELLANEOUS. 



171 



Miscellaneous. 

Fig. 86. 




Transverse section of a normal Fallopian tube (oviduct). The inside portion is made up 
of connective tissue lined by a single layer of ciliated epithelium. The circular muscular 
fibres are seen on the outside, the darker portions being spots where these involuntary 
muscles have been cut across transversely. (Landois and Stirling.) 

Fig. 87. 





Section through the advancing margin of a destructive adenoma of the stomach. (Ziegler.) 
a. Mucosa, b. Submucosa. c. Muscularis. d. Serosa. The neoplasm seen on the right of 
the drawing has started from the mucosa and has then invaded the neighboring tissue. A 
round-cell infiltration can be seen in places. 



172 



SPECIAL PATHOLOGY 



Fig. 88. 




Smallpox eruption. Portion of the skin of the forearm of a colored person, showing 
umbilicated pustules hardened in 95 per cent, alcohol. Natural size. (Drawn by Dr. G. 
K. Edwards. Post-mortem by the author.) 



Fig. 




Case of hydronephrosis due to a calculus. The kidney is 8% inches long, 5 inches wide 
and 4 inches thick. (Stone's case in the Army Medical Museum.) 



